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HANDBOOK 



OF THE 



DIAGNOSIS AND TREATMENT 



SKIN DISEASES. 



4 



BY 



ARTHUR VAN HARLINGEN, M.D., 

PROFESSOR OF DISEASES OF THE SKIN IN THE PHILADELPHIA POLYCLINIC AND COL- 
LEGE FOR GRADUATES IN MEDICINE; CONSULTING PHYSICIAN TO THE DIS- 
PENSARY FOR SKIN DISEASES, PHILADELPHIA ; PHYSICIAN 
TO THE HOWARD HOSPITAL, DEPARTMENT 
OF DERMATOLOGY. 



WITH TWO COLORED PLATES. 






... 

PHILADELPHIA N [ > o/w( S y 
P. BLAKISTON, SON & CO., 

IOI2 WALNUT STREET. 

1884. 



V 









Entered according to Act of Congress, in the year 1884, by 

P. BLAKISTON, SON & CO., 

In the Office of the Librarian of Congress, at Washington, D. C. 



TO 

JOHN MARTIN VAN HARLINGEN, Sr. 

THIS BOOK IS 

AFFECTIONATELY DEDICATED 

BY HIS SON, 

THE AUTHOR. 



PREFACE 



In writing this book I have had in mind the wants of the 
practitioner, and I have tried to make it useful as a work 
of ready reference. For this reason I have given space to 
the description, diagnosis and treatment of the various affec- 
tions of the skin as met with in practice, touching lightly on 
questions of etiology, and omitting all reference to patho- 
logical anatomy. And this, not because I undervalue such 
knowledge, but because it does not come within the plan of 
a work not intended for students of dermatology. For the 
same reason, the commoner affections and those giving most 
distress and annoyance to the patient have been treated at 
full length, while the rarer diseases and those causing little 
trouble have been dealt with briefly. The alphabetical plan 
of arrangement has also been adopted, with the object of 
ready reference in view. In the description, and chiefly in 
the definition of the various diseases, I have made frequent 
use of Duhring's well known Treatise, to which and to its 
author I desire to offer thankful acknowledgment at this time. 

129 South Fifteenth St., July, 1884. 



CONTENTS. 



. PAGE 

INTRODUCTION 9 

SYMPTOMATOLOGY 9 

Primary lesions of the skin 9 

Secondary lesions of the skin 10 

CLASSIFICATION OF DISEASES OF THE SKIN 10 

DESCRIPTION OF THE VARIOUS DISEASES OF THE SKIN IN ALPHA- 
BETICAL ORDER 11 

Acarus Folliculorum 11 

Acne 11 

rosacea 25 

Addison's Keloid, see Morphcea. 

Ainhum 29 

Albinism .' 29 

Alopecia 29 

Areata 1 33 

Angioma, see Nsevus. 

Anidrosis 38 

Aniline Dyes, see Dermatitis. 

Anthrax 39 

Argyria, see Chloasma. 

Army Itch, see Scabies. 

Arnica, Skin Diseases from Tincture of, see Dermatitis. 

Artificial Eruptions, see Feigned Eruptions. 

Atrophia Cutis, see Atrophy of Skin. 

— — — of Skin 41 

of Hair L 42 

of Nail 43 

Baldness, see Alopecia. 

Barbadoes Leg, see Elephantiasis. 
Baker's Itch, see Eczema of the hands. 
Barber's Itch, see Tinea Sycosis. 

Bed-bug , 43 

Bloody Sweat, see Purpura. 

Body Louse, see Pediculosis corporis. 

Boil, see Furuncle. 

Bromidrosis 44 

Bromine eruption, see Dermatitis Medicamentosa. 

Callositas 44 

Cancer of the Skin, see Carcinoma, Epithelioma and Sarcoma. 

Canities 45 

Carbuncle, see Anthrax. 

vii 



Ill CONTENTS. 

PAGE 

Carcinoma 46 

Chaps, see Eczema fissum and of hands. 
Cheiro-pompholyx, see Dysidrosis. 
Chilblain, see Dermatitis congelationis. 

Chloasma 47 

Chromidrosis 49 

Clavus 49 

Comedo 51 

Condyloma, see also Verruca 53 

Corns, see Clavus. 

Cornu cutaneum 53 

Crab Louse, see Pediculosis pubis. 
Crusta Lactea, see Eczema. 
Cyst, see Sebaceous Cyst. 
Dandruff, see Pityriasis capitis. 

Dermatitis 54 

Traumatica 54 

Venenata . 54 

— - — Congelationis 57 

Calorica 59 

Gangrenosa 59 

Herpetiformis 60 

Medicamentosa '. 61 

Exfoliativa 62 

Dermatolysis 63 

Dermatosyphilis, see Syphilis of the Skin. 

Dissection Wound, or Tubercle 63 

Driving in Eruptions , 64 

Dysidrosis 65 

Ecthyma 66 

Eczema 67 

in Infants 119 

marginatum, see Tinea circinata. 

Elastic Skin Man, see Dermatolysis. 

Elephantiasis 122 

Grsecorum, see Lepra. 

Ephidrosis cruenta, see Purpura. 

Epithelioma of the Skin 125 

Eruptions, Feigned, Factitious, or Artificial, see Feigned Eruptions. 

medicinal, see Dermatitis Medicamentosa. 

Erythema 130 

gangrenosum, see Dermatitis gangrenosa. 

multiforme 135 

nodosum 137 

Excoriations, Neurotic, see Neurotic Excoriations. 

Exfoliative Dermatitis, see Dermatitis exfoliativa. 

Farcy, see Glanders. 

Favus, see Tinea favosa. 

Feigned eruptions 138 



CONTENTS. IX 

PAGE 

Fibroma Molluscum, see Molluscum fibrosum. 
Filaria Medinensis, see Guinea-worm Disease. 

Sanguinis Hominis 139 

Fish-skin Disease, see Ichthyosis. 

Fissures 139 

Framboesia 140 

Freckle, see Lentigo. 

Furuncle 141 

Gangrene of the Skin, see Dermatitis gangrenosa. 

Glanders 145 

Glossy Skin, see Atrophy of the Skin. 
Graying of the Hair, see Canities. 

Grocer's Itch 145 

Guinea- worm Disease 145 

Gumma, see Syphilis of the Skin. 

Haematidrosis, see Purpura. 

Hair, Diseases of the, see Atrophy of the Hair, Hirsuties, Alopecia, Canities. 

Heat, Prickly, see Miliaria. 

Hemiatrophia Facialis, see Atrophy of the Skin. 

Hereditary Syphilis, Skin Diseases in, see Skin Diseases in Hereditary Syphilis. 

Herpes 146 

Circinatus, see Herpes iris and Tinea circinata. 

Gestationis 149 

Iris 150 

Tonsurans, see Tinea tonsurans. 

Zoster 151 

Hirsuties, see Hypertrophy of the Hair. 

Hives 154 

Hordeolum 155 

Horn, cutaneous 155 

Hydroa, see Herpes iris. 

Hyperidrosis 156 

Hyperesthesia of the Skin 160 

Hypertrophy of the Skin 161 

of the Hair 161 

' of the Nail 163 

Ichthyosis 163 

• Hystrix 166 

Impetigo 166 

Contagiosa .' 168 

Herpetiformis, see Dermatitis herpetiformis. 

Infantile Syphilis, see Skin Diseases in Hereditary Syphilis. 
Intertrigo, see Erythema intertrigo. 

Iodine Eruptions, see Dermatitis Medicamentosa. 
Itch, Army Itch, see Scabies. 

Keloid , 170 

■ of Addison, see Morphcea. 
Keratosis Pigmentosa, see Verruca senilis. 

Pilaris 172 



CONTENTS. 

PAGE 

Lentigo 172 

Lepra 172 

Leprosy, see Lepra. 

Leucoderma, Congenital, see Albinism. 

Acquired, see Vitiligo. 

Lice, see Pediculosis. 

Lichen Pilaris, see Keratosis pilaris. 

Planus, see Lichen ruber. 

Ruber 178 

Scrofulosus 180 

Simplex, see Eczema. 

Tropicus, see Miliaria. 

Lineae Albicantes, see Atrophy of the Skin. 
Lip, Fissured, see Eczema of the Lip. 

Liver Spots 181 

Louse, see Pediculosis. 

Lupus Erythematosus 181 

Exedens 185 

Vulgaris 185 

Maculae Atrophica?, see Atrophy of the Skin. 

Malignant Papillary Dermatitis, see Paget's Disease. 

Pustule 190 

Medicinal Eruptions, see Dermatitis Medicamentosa. 

Melanoderma, see Chloasma. 
Mentagra, see Sycosis. 

Miliaria 191 

Milium 193 

Mole, Pigmentary 193 

Molluscum, Contagiosum, see Molluscum Epitheliale. 

Epitheliale 193 

Fibrosum 194 

Mother's Mark, see Naevus. 

Morphcea 196 

Naevus 196 

Pigmentosus, see Mole, pigmentary. 

Nails, Diseases of. 198 

Neoplasm, Inflammatory Fungoid, see Sarcoma. 

Nettle Rash, see Urticaria. 

Neuralgia of the Skin, see Hyperaesthesia. 

Neuroma Cutis 198 

Neurotic Excoriations 198 

Nipple, Eczema of, see Eczema, also Paget's Disease of the Nipple. 

Nits, see Pediculosis. 

Noli-me Tangere, see Lupus Vulgaris. 

Odor of the Human Body, see Bromidrosis. 

Onychauxis, see Hypertrophy of the Nails. 

Onychia 199 

Syphilitic, see Syphilis of the Nail. 

Onycho-gryphosis, see Hypertrophy of the Nail. 



CONTENTS. XI 

PAGE 

Pacchydermia, see Elephantiasis. 

Paget's Disease of the Nipple 199 

Parasitic Sycosis, see Tinea Sycosis. 

Paronychia 200 

Pediculosis 200 

Capitis 201 

Corporis 202 

Pubis 203 

Peliosis Rheumatica, see Purpura. 

Pellagra 204 

Pemphigus 204 

Syphiliticus, see Syphilis of the Skin. 

Perforating Ulcer of the Foot 207 

Petechia? — 207 

Phosphorescent Sweat 207 

Phthiriasis, see Pediculosis. 

Piebald. Skin, see Vitiligo. 

Pigmentary Mole and Naevus, see Mole. 

Pityriasis Simplex (capitis) 207 

Rosea 210 

— ; Pilaris, see Keratosis Pilaris. 

Rubra 211 

Versicolor, see Tinea Versicolor. 

Plica Polonica 212 

Pompholyx, see Dysidrosis. 

Porcupine Disease, see Ichthyosis Hystrix. 

Porrigo , 213 

Port-Wine Mark, see Neevus. 
Prickly Heat, see Miliaria. 

Prurigo 213 

1 Senilis, see Pruritis and Pediculosis corporis. 

Pruritus 214 

Hiemalis 221 

Psoriasis 222 

Purpura 230 

Quinine Eruption, see Dermatitis Medicamentosa. 

Rhus Poisoning, see Dermatitis Venenata. 
Ringworm, see Tinea circinata. 
Rodent Ulcer, see Epithelioma. 
Rupia, see Syphilis of the Skin. 

Sapo Viridis , 233 

Sarcoma of the Skin 233 

Scabies 234 

Sclerema neonatorum 236 

Scleroderma 237 

Scrofuloderma 237 

Scurvy, Land, see Purpura. 

Sebaceous Cyst : 240 

Seborrhcea 240 



Xll CONTENTS. 

PAGE 

Shingles, see Herpes Zoster. 
Smegma, see Seborrhoea. 
Strophulus, see Miliaria. 
Stye, see Hordeolum. 

Sudamen . 244 

Sweat, Bloody, see Purpura. 

Colored, see Chromidrosis. 

Phosphorescent, see Phosphorescent Sweat. 

Sweating, Excessive, see Hyperidrosis. 

Sycosis 245 

Non-parasitica, see Sycosis. 

Parasitica, see Tinea Sycosis. 

Syphilis of the Skin 248 

Skin Diseases in Hereditary Syphilis 255 

Syphiloderma, see Syphilis of the Skin. 
Telangiectasis, see Nzevus. 

Tetter 259 

Tinea 259 

Circinata 259 

Decalvans 260 

Tonsurans 261 

Kerion 263 

Sycosis 263 

Favosa 264 

Versicolor 266 

Tooth Rash, see Eczema in children. 

Ulcer , 268 

Rodent, see Epithelioma. 

Uridrosis 268 

Urticaria 268 

Vaccination, Skin Diseases Following 273 

Vegetations, see Verruca and Syphilis, Skin diseases due to. 

Venereal Wart, see Verruca. 

Vernix Caseosa, see Seborrhoea. 

Verruca , 274 

Necrogenica, see Dissection Wound. 

Vitiligo 276 

Wart, see Verruca. 
Wen, see Sebaceous Cyst. 
Xanthelasma, see Xanthoma. 

Xanthoma 277 

Xeroderma, see Ichthyosis and Atrophy of the Skin. 

Yaws, see Frambcesia. 

Zoster-Zona, see Herpes Zoster. 

APPENDIX— DIET IN DISEASES OF THE SKIN 279 



DISEASES OF THE SKIN. 



INTRODUCTION. 

Symptomatology. In order to gain a satisfactory con- 
ception of the nature of any given skin disease in itself 
considered, we must have a clear idea of the character and 
appearance of the individual lesions which go to make up 
the objective picture known as the eruption. These are of 
two kinds, primary and secondary. 

Primary Lesions of the Skin. These are such as 
show themselves as the original forms of disease. They are : 
macules, papules, vesicles, blebs, pustules, wheals, tubercles and 
tumors. 

Macules are variously sized, shaped and colored portions 
of altered skin, unaccompanied by elevation or depression. 
The common freckle is an example of this lesion. 

Papules are circumscribed, solid elevations of the skin, 
varying in size from a pin head to a split pea. The pimply 
eruption of acne, when the lesions are solid and without any 
pus, is a good example of a papular eruption. 

Vesicles are circumscribed, rounded elevations of the epi- 
dermis, varying in size from a pin point to a split pea, 
containing a clear, serous fluid. The watery pimples seen 
in the rash caused by exposure to poison ivy are typical 
examples of vesicles. 

Blebs are irregularly shaped elevations of the epidermis, 
varying in size from a split pea to a goose-egg, containing 
2 9 



10 DISEASES OF THE SKIN. 

a clear or opaque fluid. The raised watery blisters of a 
burn are blebs. 

Pustules are circumscribed, rounded elevations of the 
epidermis, varying in size from a pin point to a finger nail, 
containing pus. The pimples of acne, when these show 
a mattery head, are pustules. 

Wlieals are firm, flat, elongated or rounded, slightly raised 
elevations, which come and go quickly. The lesions of 
" nettle rash" or "hives" are typical wheals. 

Tubercles are firmly seated, solid elevations of the skin, 
varying in size from a split pea to a cherry. Small wens are 
tubercles. 

Tumors are variously sized, shaped and constituted, firm or 
soft prominences. Large wens are tumors. 

Secondary Lesions of the Skin. These are such as exist 
either as the result of primary lesions or from other causes. 
They are : crusts, scales, excoriations, fissures, ulcers and scars. 

Crusts are effete masses of dried material composed of the 
products of disease of the skin. 

Scales are dry laminated masses of epidermis which have 
separated from the tissues beneath. 

Excoriations are losses of tissue occurring in the superficial 
layers of the skin. 

Fissures are linear wounds having their seat in the epi- 
dermis or corium. 

Ulcers are irregularly sized and shaped excavations of the 
cutaneous tissues, the result of disease. 

Scars are new formations occupying the place of former 
normal tissue. 

Classification of Diseases of the Skin. The classifi- 
cation of diseases of the skin now most generally employed 
by dermatologists is that of Hebra, which with slight modifi- 
cations has been adopted by the American Dermatological 
Association. It includes the following nine classes : — 



ACNE. 11 

I. Disorders of the Glands ; (i) of the sweat glands ; 
(2) of the sebaceous glands. 
II. Inflammations. 

III. Hemorrhages. 

IV. Hypertrophies ; (1) of pigment ; (2) of epidermis 
and papillary layers; (3) of corium. 

V. Atrophies. 

VI. New Growths ; (1) of connective tissue ; (2) of 
vessels ; (3) of granulation tissue. 
VII. Ulcers. 
VIII. Neuroses. 
IX. Parasitic Affections ; (1) vegetable ; (2) animal.* 



DESCRIPTION OF THE VARIOUS DISEASES OF THE 
SKIN, IN ALPHABETICAL ORDER. 

Acarus Folliculorum (ix), more properly Demodex 
Folliculorum, is a minute, worm-like parasite, not unfrequently 
found in the sebaceous follicles. It gives rise to no symp- 
toms whatever of disease, but is occasionally pictured in 
quack advertisements, to frighten the ignorant. The worm- 
like plugs of altered sebaceous matter which can be expressed 
from greasy skins, particularly on the face and nose, are 
occasionally mistaken for parasites, and are called "flesh 
worms" or "grubs." (See Comedo.) 

Acne (iii) is an inflammatory, usually chronic, disease 
of the sebaceous glands, characterized by the formation of 
papules, tubercles or pustules, or a combination of these 
lesions, occurring for the most part about the face. It may 
occur alone or in connection with other affections of the 
sebaceous glands, as comedo and seborrhoea. The lesions 

* In the following pages, the various diseases being arranged alphabeti- 
cally, no system of classification will be possible, but a figure designating 
the class to which each disease belongs will be placed after its title. 



12 DISEASES OF THE SKIN. 

are of various sizes, from a pin's head to a large split pea, 
and are commonly seen in both the papular and pustular, 
or the tubercular and pustular forms combined. The lesions 
are acutely inflammatory, but are not often accompanied by 
burning, itching, or in fact by any subjective symptoms, 
excepting occasionally a feeling of soreness when touched. 
Their color may vary from bright red to dusky or violaceous, 
with usually a pustular centre. The number of lesions varies 
greatly in different cases. There may be only one or two, or 
they may be very numerous. The inflammation may be super- 
ficial, or it may be deep, and even occasionally leading to the 
formation of abscesses. The individual lesions may come and 
go in a few days, or they may be of slow evolution, but the 
disease itself is apt in all cases to run a chronic course, the 
process frequently lasting for years. If there has been much 
suppuration, more or less unsightly scars may remain. 

The chief seat of acne is upon the face, neck, shoulders 
and chest, although it may occur upon any part of the body 
except the palms and soles. The severity of the disease varies 
very greatly. In some instances it may be represented by one 
or two lesions only, while in others the face, neck, shoulders, 
chest, and even the whole trunk, may be covered with un- 
sightly papules, pustules, suppurating tubercles and abscesses. 

Acne is one of the commonest diseases of the skin. In 
this country the statistics of the American Dermatological 
Association show its occurrence in the practice of specialists 
to be in the proportion of seven per cent, among all diseases 
of the skin. I am inclined to think this an under-statement 
of the relative frequency of the disease. Many cases go 
untreated because patients have been assured by the family 
physician that the disease is incurable, or that it will get well 
of itself in time, or that it will not do to drive it in, etc. ; 
refuges of ignorance which may satisfy the conscience of the 
physician, but which entail at times a great amount of shame 



ACNE. 13 

and humiliation on young persons, particularly women, solicit- 
ous of their appearance. Acne occurs in the young of both 
sexes, appearing about the age of puberty. It does not occur 
in children, and only rarely makes its appearance for the first 
time in mature years. 

Papular acne is chiefly characterized by the occurrence of 
papular lesions, of pin-head to small pea size, flat, or more or 
less pointed, lightish in color, situated about the sebaceous 
follicles, and often showing a minute black point, which indi- 
cates the mouth of the sebaceous duct. This variety of acne, 
sometimes known as acne punctata, is often accompanied by 
comedones. (See Comedo?) The lesions, though commonly 
most plentiful over the forehead, are also frequently met with 
on the face and elsewhere. There are usually a few pustular 
lesions scattered among the papules. The latter are not 
inflammatory, and papular acne is the least developed form 
of the disease. 

Pustular acne is the typical form of the disease, though 
even when fully developed pustules form the chief feature 
of the eruption, many lesions of a papular and intermediate 
character are found. The pustules are pin-head to large 
pea sized, rounded or acuminated, seated on a more or less 
infiltrated base of superficial or deep inflammatory product. 
Suppuration may be slight or abundant. When the base is 
deeply infiltrated the affection is known as acne indurata. 
This last form sometimes runs into the production of ab- 
scesses, which appear chiefly on the face and down the 
shoulders and back, forming the most serious and annoying 
phase of the disease. Indurated acne is apt to result in the 
formation of cicatrices, of a pitted or atrophic character, which 
are quite disfiguring. Sometimes keloid occurs as a result 
of indurated acne, the lumpy scars lasting some months, but 
finally disappearing spontaneously. 

Artificial acne is sometimes observed as the result of the 



14 DISEASES OF THE SKIN. 

external employment of tar and other substances. The so- 
called bromine and iodine acne will be described under another 
head. (See Dermatitis.) - 

The causes giving rise to acne are numerous and varied in 
their nature. I know of scarcely any other disease of the 
skin in which the satisfactory result of treatment depends so 
much upon the recognition of the exciting cause. In its 
commoner forms it appears to be dependent to some extent 
upon the character of the skin. Persons with thick, oily 
skins are most apt to suffer from the diffuse form of acne, 
with numerous papular and pustular lesions mingled with 
comedones, while the sparse eruption of flat and papular 
lesions is often found in pale anaemic individuals with dry, 
rather harsh skins. The most frequent cause of acne is 
puberty. The affection shows itself for the first time, in the 
vast majority of cases, at this period, and is apt to continue, 
unless remedial measures are adopted, until the system has 
assumed the equilibrium of adult life, or in women until a 
later period. It is at the period of puberty that the sebaceous 
system takes on a new activity, the hairs begin to develop, 
and there is a sort of normal hyperaemia about the follicles, 
which may easily determine an abnormal condition resulting 
in the development of sebaceous disorders. 

Other causes which may, either alone or combined, give 
occasion to the occurrence of acne, are scrofula and cachexia 
or general debility. Anaemia and chlorosis may also be men- 
tioned in close connection with these other causes, as favoring 
the development of acne. 

Of great importance in the causation of acne, and espe- 
cially in favoring its continuance, is habitual derangement 
of the alimentary canal. Dyspepsia and constipation will 
be found present in the majority of cases, and often in such 
intimate relation to the disease that a fresh crop of lesions 
shall follow every attack of indigestion or of costiveness. 



ACNE. 15 

Uterine disorders, especially of a functional character, are 
often the direct cause of acne ; but at other times the cause of 
the affection seems beyond finding out, the patient remaining 
in an apparently perfect condition of general health. 

The diagnosis of well-developed acne presents no diffi- 
culties. We often meet with cases, however, where only a 
few imperfectly developed lesions are present, and where 
the affection may easily be mistaken for others of a widely 
different character. The age of the patient, the seat of the 
lesions, their chronic character and their inflammatory nature 
must be taken into account. The acneform eruption caused 
by tar may be recognized usually by the smell of that sub- 
stance, and its presence in the follicles giving the appearance 
of numerous black points. In the eruption caused by bromine 
and iodine (see Dermatitis) the lesions are apt to be larger, 
of a brighter and more acutely inflammatory nature, and, 
when well-developed, the lesions tend to coalesce and to 
form elevated inflammatory areas covered with characteristic 
sebaceous crusts. Acne often closely resembles the papular 
and pustular syphilo-dermata, and great care must often 
be taken to avoid mistakes in diagnosis. The history, the 
absence of syphilitic lesions on other parts of the body than 
those commonly affected by the eruption of acne, the uniform 
distribution of the lesions, those of syphilis tending to group, 
all serve to denote the presence of acne. When syphilis 
occurs on the forehead, or in one or two lesions on the nose 
alone, as I have sometimes seen it, without any history what- 
ever, it is extremely apt to be taken for acne, and great caution 
must be exercised in coming to a decision as to the nature of 
the affection in a case seen for the first time. Severe cases 
of acne are sometimes taken for variola, but this can hardly 
occur if a careful examination is made into the general 
symptoms and history of the eruption. 

The treatment of acne is of two sorts, constitutional and 



16 DISEASES OF THE SKIN. 

local. In order to treat a case of acne with any hope of 
success, we must first ascertain the causes which have oper- 
ated in bringing it about. The foundation of the successful 
treatment of acne lies in the knowledge of its etiology. The 
patient should be carefully examined regarding every organ 
and every function. The habits of life, the surroundings, 
the occupation of the patient, should all be known to the 
physician, who should also study the case well, to discover, 
if possible, what is the exact cause or group of causes of 
which the acne eruption is the expression and the result. 
Without this little can be hoped for, and acne is one of the 
minor opprobria of medicine, chiefly because the physician 
cannot or will not take the trouble to enter into the patient's 
case with the persevering thoroughness which is indispens- 
able. It should be the aim of the physician to prevent the 
appearance of the lesions. External treatment will rarely 
accomplish this, and internal measures must therefore be 
employed in almost every case. From what has been said 
under the head of etiology it will be perceived that in gene- 
ral the patient's health must be looked after. If anaemic, 
tonics are required, among which iron and arsenic are promi- 
nent ; if the uterine functions are not regularly performed, 
these must be regulated ; if dyspepsia exists this must be 
combated by diet, regimen and the remedies appropriate to 
the condition. Constipation is a frequent concomitant with 
acne, and its removal is necessary to a cure. Acidity of the 
stomach, flatulence, a coated tongue, are ordinary symptoms, 
and these, together with irregular and perverted appetite, are 
constantly met with in the affection under consideration. 
If constipation exist, saline or vegetable laxatives should 
be prescribed in sufficient quantity to open the bowels once 
or twice in the day. An occasional mercurial, as blue pill 
or a compound cathartic pill, may be prescribed in some 
cases. The admirable mixture devised by the late Mr. 



ACNE. 17 

Startin, of London, known as "mistura ferri acida," is one of 
the most valuable aperient tonics which can be given for acne 
accompanied by constipation. It is composed as follows : — 

]£. Magnesii Sulphatis ^j 

Ferri Sulphatis gr. iv 

Sodii Chloridi gss 

Acidi Sulphurici dil f ^ ij 

Infus Quassise ad f|>i v - M. 

SlG. — A tablespoonful in a tumbler of water, before breakfast. 

This preparation, though extremely disagreeable on first 
taking, becomes less revolting after using for a short time, 
and most persons, even delicate women, can take it without 
repulsion. The various ingredients may be altered in quantity 
in various cases, to suit circumstances, but it is not often 
necessary to make any change excepting as to the sulphate 
of magnesium, which must often be increased in quantity if 
a full aperient effect is desired, or the dose of the formula as 
given may be repeated before dinner, or even administered 
thrice daily. The natural mineral waters are used with good 
success in acne. The Hathorn and Geyser springs of Sara- 
toga, the German Friedrichshall, Hunjadi Janos and Ofener 
Racoczy, all cathartic, are of use, the dose, of course, vary- 
ing with the amount of constipation present. 

When there is much irritability and hypersemia accom- 
panying the acne, good results are often gained by the 
administration of alkalies over a period of two or three 
months. The acetate of potassium alone, in the dose of half 
a drachm or mixed with Rochelle salts, is recommended by 
Dr. Taylor in the following formula: — 

R. Potassii Acetatis Jj 

Sodii et Potassii Tart ^ij 

Syr. Zingiberis f 3j ij 

Aquse q. s ad f^ viij. M. 

SlG. — A tablespoonful in a wineglassful of water, after meals. 

There are many cases of acne, however, which depend 



18 DISEASES OF THE SKIN. 

upon some general derangement of the system, the scrofulous 
taint, anaemia, etc., and these must be treated quite differ- 
ently. Cod-liver oil will in many such cases be found a very 
efficient curative agent, particularly when the lesions are in- 
durated and tend to extensive multiplication over the trunk 
as well as the face, with the formation of numerous abscesses. 
The compound syrup of the hypophosphites is likewise of 
benefit in these cases, as is also the extract of malt, which 
may be employed in some instances to replace cod-liver oil, 
when this is found to disagree. The bitter and ferruginous 
tonics are occasionally called for in this class of cases, and 
the mineral acids are often of value. 

The following combination of iron with a mineral acid 
has sometimes proved of value in my hands when dyspeptic 
symptoms with anaemia coexist with the eruption of acne : — 
R • Tinct. Ferri Chlor. 

Acid Phosphoric dil....aa... f,^j 

Syrupi Limonis f* ^ i j . M. 

Sig. — Teaspoonful in a wineglass of water thrice daily, after meals. 

Among alteratives arsenic stands first, sometimes appearing 
to act almost as a specific in anaemic cases. It may be given 
conveniently in the form of Fowler's solution, in two to four 
minim doses, gradually increased until the limit of tolerance 
is reached and then dropped a little below this and continued 
for a considerable period. The following formula is a favorite 
with me, it combines the arsenic with iron : — 

R . Liq. Potassii Arsenitis fgij 

Vini Ferri ad f^ v - M. 

Sig. — Teaspoonful in water, after meals. 

Fowler's solution should never be prescribed alone, to be 
given in drops. This is an inconvenient and not altogether 
safe method of administration. Patients cannot be trusted 
to drop out the medicine with the requisite care ; the size of 
the drop may vary with different bottles ; and it is always 
dangerous to allow a bottle of concentrated and poisonous 



ACNE. 19 

medicine to go into the hands of unskilled and perhaps care- 
less people. If it is desired to omit the iron, the arsenic 
may be given in cinnamon water or in plain water as I often 
prescribe it. It should not be mixed with syrup of orange, 
etc., as is sometimes recommended ; patients are apt to revolt 
against the cloying sweetness, and it not unfrequently dis- 
agrees. I may say here that iron does not agree with some 
acne patients. As Dr. Fothergill says, iron does not agree 
with "bilious" people. Instead of arsenic, mercury may 
be given. Dr. Taylor prefers the following formula : — 

]£. Hydrarg. Bichloridi gr. j 

Ammoniae Muriat gr. vj 

Tinct. Cinchonae Comp f ^iij 

Aquae f Jjj. M. 

Sig. — Teaspoonful in a wineglass of water three times a day, an hour 
after meals. 

The dose here is the thirty-second of a grain, which may 
be increased every ten days until in general one-quarter of 
a grain is reached. The effect of this treatment begins in 
about two or three weeks. Of course, it is not to be under- 
stood that syphilis is suspected in the cases in which mercury 
is recommended. It is simply as a tonic alterative. In cases 
when it may be desired to combine mercury and arsenic, 
Dr. Taylor recommends " De Valangin's solution," liquor 
arsenici chloridi, which can be given in connection with the 
bichloride of mercury. The dose of this solution is the same 
as that of Fowler's solution. The sulphur mineral waters, as 
those of Richfield, Sharon, Avon, and the White Sulphur of 
Virginia, have a reputation for beneficial influence in acne ; 
but I am inclined to believe that there is nothing specific in 
the effects of the waters themselves ; and whatever good may 
be effected is gained by the pure air and general tonic effect 
of the surroundings. The influence of sulphur waters is 
generally upon the liver and intestines, and thus, indeed, they 



20 DISEASES OF THE SKIN. 

may be of indirect benefit in acne. Hygiene, in the form 
of fresh air, exercise, cold bathing, and a sojourn in the 
country or by the seashore, will now and then effect what 
medicines may fail to do. It should be added that the sea- 
shore life occasionally is found to disagree violently with 
acne patients, bringing out the eruption in great abundance. 
Inquiry should be made before sending patients to the sea- 
shore, and they should be directed to change at once if the 
climate should prove unsuitable. 

The local treatment of acne is important, and especially so 
with regard to the choice of remedies. There is perhaps no skin 
disease in which so many local applications have, at one time 
or another, been recommended. Used with discretion a few 
will suffice, but the great number of formulae extant serve 
only to confuse the practitioner in search of an appropriate 
topical application. For this reason I shall give only a 
selection of those ordinarily used, and this shall embrace 
the preparations which I am accustomed to employ daily in 
my own practice, and which I can therefore vouch for from 
extensive personal knowledge of their good effect. 

The external treatment of acne may be either soothing or 
stimulating. In a small number of cases there is much heat, 
redness and acute inflammation present, and here mild washes 
and bland ointments, such as those to be given under the 
treatment of eczema of the face, will best answer. In most 
cases, however, stimulant applications are called for. When 
the skin is rather coarse and sluggish the face may be rubbed 
and washed every night with the soap known as ' ' sapo viridis, ' ' 
an imported soft soap, the use of which was introduced into 
this country from Germany. It is of the consistency of 
ointment, and contains a slight excess of caustic potash. The 
solution of this soap in one-half its weight of alcohol, known 
as " spiritus saponis kalinus," may be used instead of 
the soap itself, when a milder effect is desired. A small 



ACNE. 21 

portion of soap or a few drops to half a teaspoonful of the 
spiritus saponis should be rubbed briskly over the affected 
skin for several minutes. It must be remembered that these 
are strongly stimulant preparations, and their chief use is to 
cause absorption when the lesions are sluggish and indurated. 
They should be washed carefully off after use, and the part 
covered with powdered starch or a small quantity of cold 
cream or some other bland ointment. If they make the 
skin harsh, their use should be suspended or stopped. 
When the sebaceous gland ducts are unhealthy and plugged 
up, and when comedones abound, the soapy applications, 
especially if combined with copious bathing with hot water, 
loosen and aid in pressing out the plug of inspissated sebum, 
and in returning the glands to a more healthy condition. 
The watch key may also aid here, in pressing out the come- 
dones present. (See under Comedo.) A still stronger applica- 
tion sometimes employed in these cases is a fifteen grain 
solution of caustic potash in water. This may be followed 
by a stimulant ointment, as the following : — R. Ung. precip. 
alb., 3J, ung. aquae rosae, ^iij. The oxide or nitrate of 
mercury ointments may be substituted if a stronger effect 
is desired. Sulphur and its preparations are among the 
most valuable remedies in our possession for the treatment of 
acne in most of its forms. The following may be given as 
among the most eligible sulphur compounds with which I 
have had experience : — 

R. Sulphuris Prsecipitat gj 

Ung. Aquas Rosae, 

Ung. Petrolii aa ^iv. M. 

Camphor may sometimes be added, with advantage : — 

R. Sulphuris Praecipitat ^j 

Pulv. Camphorae gr. xx 

Ung. Aquae Rosae, 

Ung. Petrolii aa giv. M. 



22 DISEASES OF THE SKIN. 

Among lotions containing sulphur the following may be 
mentioned as being particularly useful : — 

R. Sulphuris Praecipitat ^j 

Pulv. Camphoras gr. v 

Pulv. Tragacanthas gr. x 

Aquas Calcis, 

Aquas Rosas aa f^j. M. 

This exercises a markedly astringent effect upon the skin, 
and may be used in cases where there is a tendency to 
rosacea. 

The solution known as that of " Vlemingckxs' " comes 
into play in sluggish and non-inflammatory forms of acne. 
It is almost caustic, and must be diluted with from two to 
four times its volume of water at first, until its effect upon 
the skin of the individual has been ascertained ; it is made 
as follows : — 

R. Calcis Vivas % ss 

Sulphuris Sublimat ^j 

Aquas H§ x. M. 

Boil down to six ounces and filter. 

A mixture of sulphur, ether and alcohol works well in a 
certain number of cases : — 

R. Sulphuris Loti £j 

^theris fgvj 

Alcoholis f^iiiss. M. 

SlG. — Shake well before using. 

Among the compounds of sulphur the following are fre- 
quently beneficial in the papular and pustular forms of 
acne : — 

R. Potas. Sulphured J)j 

Tinct. Benzoini fgj 

Glycerinas f^iss 

Aquae Rosas f ^ iv. M. 



ACNE. 23 

Another prescription which is a favorite of mine is the 
following: — 

R. Potassii Sulphuret, 

Zinci Sulphat aa £j 

Aquae Rosae f^ iv. M. 

The ingredients are each dissolved in one-half the water, 
forming clear solutions. They are then mixed, and a white 
precipitate takes place, which is to be shaken up and allowed 
to dry on the face. 

The following mercurial preparation is of use in papular 

acne : — 

R. Ung. Hydrarg gj 

Ung. Petrolii 3 u j- M. 

In a certain number of cases bichloride of mercury seems 
to act better than other preparations. A convenient formula 
is the following: — 

R. Hydrarg. Bichlor. Corros gr. ss 

Emuls. Amygdalae Amar f % iv 

Tinct. Benzoini f^ss. M. 

SlG. — Apply at night. 

The corrosive chloride of mercury constitutes the basis of 
the majority of the lotions for the toilet and cosmetics sold 
in the market. 

Mercurial and sulphur preparations should not be used 
simultaneously. 

Two preparations highly recommended by competent 
dermatologists, are these : — 

R. Chrysarobini £ss 

Collodii fjj. M. 

Put a brush in the cork and paint on the lesions every evening. 

(Geo. H. Fox.) 

R. Zinci Iodidi gr. v-xxv 

Ung. Petrolii Jj. M. 

(R. W. Taylor.) 



24 DISEASES OF THE SKIN. 

Indurated and pustular acne may sometimes be benefited 
by the application to each lesion of solution of the acid 
nitrate of mercury, on the end of a sharpened match, fol- 
lowed by bathing with hot water. Puncture with the point 
of a fine bistoury or with a lance especially designed for 
this purpose, is a good procedure in indurated acne with a 
tendency to the formation of abscesses. 

Other and severer remedies for acne have been recommended 
by authors, but I have had little experience with them, and 
believe that, in this country at least, the severer measures will 
usually prove too much for the skin, and will be more apt to 
prove injurious than beneficial. 

Whatever plan of treatment is adopted, it is of the utmost 
importance that it be thoroughly carried out. The physician 
should, at first especially, see the patient every day or every 
few days, to ascertain if his directions are being properly 
followed. As Taylor remarks, much of the discredit which 
is attributed to physicians in the treatment of acne is due to 
two causes : first, either that they are not sufficiently careful, 
precise and emphatic in giving the directions for treatment ; 
or secondly, that the patients only carry out their directions 
in an imperfect and indifferent manner. Always give the 
patient to understand that unless he does what the physician 
directs him to do, to the letter, the latter is not in any way 
responsible for his cure. 

The prognosis of acne should always be guarded. While 
by no means the desperate and incurable malady which it is 
sometimes said to be, by pessimistic or incapable practitioners, 
it yet often offers a stubborn resistance to treatment, and shows 
a marked tendency to relapse. The most extensively de- 
veloped cases, moreover, are sometimes more amenable to 
treatment than those where half a dozen lesions alone 
represent the disease, and where the patient enjoys apparently 
good health. The question is, in the long run, one of time 



ACNE ROSACEA. 25 

only, as a spontaneous cure sooner or later invariably occurs. 
If neglected, however, unsightly and disfiguring scars super- 
vene in severe cases, and our efforts, therefore, should be 
unremitting to obtain a speedy cure if possible. 

Now and then keloid follows as a result of pustular acne. 
This condition, though unsightly and disfiguring, disappears 
spontaneously with the lapse of time, perhaps in three to 
twelve months. Treatment fails to hasten its disappear- 
ance. 

Acne Rosacea (iii). Acne rosacea is a chronic, hyper- 
aemic or inflammatory disease of the face, more particularly 
the nose, characterized by redness, dilatation and enlarge- 
ment of the blood vessels, hypertrophy and more or less 
acne. Hypersemia, or flushing, is the earliest symptom, inter- 
mittent at first and noticeable only after exposure to a close 
atmosphere or following the use of alcoholic stimulants or a 
full meal. This hypersemia is passive, at first ; the nose is cold 
to the touch and often shows slight seborrhcea. Gradually 
the redness grows more marked and permanent. If now the 
nose is examined, small, tortuous blood vessels can be seen 
ramifying in the skin of the affected part. Sooner or later 
acne papules and pustules are apt to show themselves, as a 
rule, however, few in number. The disease varies in intensity 
in different cases, from a slight blush to a marked deformity. 
The face and nose are the parts usually attacked. The course 
of the disease is chronic, sometimes extending over years. 
The process usually goes no further than the formation of 
swollen and tortuous blood vessels with diffuse redness, but 
sometimes hypertrophy of the connective tissue takes place, 
with grotesque enlargement and deformity of the nose, which 
becomes knobby, irregular in shape, and may grow to enor- 
mous size. 

The causes of acne rosacea are various. It occurs both in 
men and women, but in the latter does not often tend to go 
3 



26 DISEASES OF THE SKIN. 

beyond the first stages. In women also the disease is more 
prone to occur at two periods of life, at early womanhood 
and at the climacteric period. When occurring in young 
women, seborrhcea is apt to be present, and the disease 
appears to be due, in some measure certainly, to dyspepsia, 
anaemia, chlorosis and menstrual difficulties. It usually goes 
away but may return in later life. Wheri it occurs in later 
life it is apt to be more severe. In men the disease may 
occur at any period. In early life it is generally due to 
anaemia and debility, nervous prostration and dyspepsia. In 
later life the use of spirituous liquors is often the cause ; and 
perhaps nearly as often, dyspepsia in some of its forms. 
Habitual indulgence in alcoholic or malt liquors gives rise 
to this condition in various regions of the face. 

The treatment of acne rosacea depends upon the stage of 
the disease and upon its cause in the given case. Constitu- 
tional and local remedies are both used. The causes giving 
rise to the affection should be diligently sought for and 
removed, when possible. Uterine and menstrual derange- 
ments are to be looked after, the stomach and bowels kept 
in good order, and all hygienic measures used to improve 
the general health. Alcoholic and malt liquors are to be 
totally eschewed. Tea and coffee should be drunk in modera- 
tion and not strong. Inveterate tea drinkers are very apt 
to have red noses. Tea is often made to take the place of 
food, and gradually brings on a sort of dyspepsia peculiar 
to itself. The food should be of the plainest character. The 
general medical treatment is that of acne. Local treatment, 
however, is of the most value. Sulphur lotions, as in acne, 
may be used in the early stages, the following formula being 
a useful one : — 

R. Sulphuris Prsecipitat 3.HJ 

Ung. Aquae Rosae ^j. M. 

Sometimes sulphur lotions are more useful. The following 



ACNE ROSACEA. 27 

will be found an efficient combination. It appears to exercise 
a decidedly astringent effect : — 

ljt . Sulphuris Praecipitat 3J 

Pulv. Camphorae, gr. v 

Pulv. Tragacanthae gr. x 

Aquae Calcis, 

Aquae Rosse aa f^j. M. 

This may be applied once to several times a day. In one 
of the most rapid cures of rosacea I ever observed, the patient 
kept putting on successive layers of the wash every few hours 
until her face was covered with a thin yellow crust. Some- 
times the wash seems to draw the skin and gives rise to an 
uncomfortable sensation. In this case the sulphur ointment 
mentioned just above may be applied in small quantity after 
each application of the wash. On the whole, I have gotten 
more benefit for patients out of this wash than any other, 
and I count it the best application in acne rosacea. It will 
not always do good however, and we are sometimes driven 
to try other plans of treatment. A wash of corrosive subli- 
mate, of the strength of one- fourth grain to two grains to 
the ounce of alcohol, or in ointment, sometimes answers well 
in the first stage of the disease. Neumann and Hebra re- 
commended mercurial plaster spread on cloths. Geo. H. 
Fox suggests the employment of chrysarobin : — 

R. Pulv. Chrysarobin ^ss 

Collodii f:§j. M. 

To be painted on the skin. 

Of course, this is to be watched, lest the irritative effect 
of chrysarobin be produced. In the second stage, when 
numerous well-defined blood vessels can be seen coursing 
under the skin, the treatment must be somewhat different. 
The dilated capillaries may be incised with a sharp knife, 
in the hope that adhesive inflammation may result, with the 
effect of closing the calibre of the vessels. Cold water com- 



28 DISEASES OF THE SKIN. 

presses are to be applied subsequently, to control the bleed- 
ing, and a small number of vessels may be thus operated 
upon every day or two, until the ground has been thoroughly 
gone over. Another treatment is painting the affected parts 
once or twice weekly with a ten- to twenty -grain solution of 
caustic potassa and following this by an emollient poultice. 
In cases where there is but little thickening, carbolic acid 
dissolved in three to four parts of alcohol may be painted 
on the part every second day. Hardaway recommends elec- 
trolysis, using a number thirteen cambric needle inserted 
into any convenient handle, and connected with the negative 
pole of a galvanic battery. A sponge electrode is then 
connected with the positive pole. The needle is inserted 
sufficiently deep to enter the dilated vessel; so soon as this 
has been accomplished, the patient completes the circuit by 
taking the sponge electrode in his hand. So soon as the 
electrolytic action has been properly developed, the patient 
releases the sponge electrode, after which the operator with- 
draws the needle. Six to eight elements will generally suffice. 
If the vessel to be operated upon is a long one several punc- 
tures must be made at suitable intervals of space. The needle 
may be inserted perpendicularly or in a line with the course 
of the vessel. In those rare and severe cases where knobby 
and gross deformity of the nose exists, decortication with the 
knife is the only remedy. 

The prognosis in the early stages is favorable and there are 
few affections of the face in which more striking and rapid 
results can be attained, up to a certain point, than in those 
cases of acne rosacea where there is a "red face" with 
numerous papular and pustular lesions, with little or no 
capillary dilatation. When, however, the disease has become 
thoroughly established, only thorough and long continued 
treatment will avail. Where the capillary enlargement is 
already marked, .treatment beyond a certain point is only 



ALOPECIA. 29 

palliative ; it may prevent further progress, but this is much, 
and patients should be encouraged to persevere. 

Addison's Keloid. (See Morphea.') 

Ainhum (vi) is a disease peculiar to the African race, char- 
acterized by a slow, progressive, fatty degeneration, generally 
with increase in volume of the toes, especially of the smallest, 
resulting from a linear strangulation. The constriction, after 
four to ten years, forms a deep, circular furrow, and eventu- 
ates in snapping off of the toe. Brazil and the West Coast 
of Africa are the commonest localities of the disease, but 
within the last few years cases have been reported from the 
southern United States. Recent pathological investigations, 
particularly those of Wile, point to the intentional and per- 
sistent application of a ligature by the patient as the cause. 
The only treatment, after strangulation has been effected, is 
the early removal of the useless and cumbersome member. 

Albinism (v). The condition which has been termed 
albinism consists in a congenital absence of the normal pig- 
ment. It may be partial or general. In the latter case the 
subjects are known as albinos. Here the skin is of a milky- 
white or pinkish color, the hair white, yellowish-white or red, 
and even the iris and choroid of the eye are more or less de- 
prived of pigment. When occurring in the negro race those 
affected are called " piebald." In the latter the eyes are not 
affected, and cases are on record where the color of the 
affected patches, has returned. This affection is to be care- 
fully distinguished from vitiligo, q. v. 

Alopecia (v). Alopecia is a condition of more or less 
complete baldness, resulting from a deficient growth of the 
hair. It may be considered under the heads of congenital, 
senile, idiopathic premature and symptomatic premature. 

Congenital alopecia is the name given to those rare forms of 
the disease where an individual is born without hair. In one 
such case microscopic examination showed absence of hair 



30 DISEASES OF THE SKIN. 

bulbs. I am familiar with the case of an otherwise healthy 
infant, upon whose scalp only lanugo (fine downy hairs) grew 
until after the third year of life. A hereditary predisposition 
to scanty growth, or early loss of hair, may often be traced. 

Senile alopecia, or the baldness of old age, is connected 
with the general atrophy of the cutaneous tissues, which occurs 
at this period of life. The hairs become gray, thin and dry, 
and are cast off not to be renewed. The hairs of the body 
generally become thinner, and drop out to a less extent, at 
the same time. 

Idiopathic premattire alopecia, or premature baldness, may 
take place either rapidly, in the course of weeks or months, 
or, as is most generally the case, slowly through a period of 
years. The hair may begin to come out at any period after 
puberty, although it does not generally fall much before the 
age of twenty-five to thirty. The scalp is healthy, to all ap- 
pearance, no pityriasis being present. At first only a few 
hairs fall, and these are succeeded by new ones growing from 
the same follicles, but coming earlier to maturity and falling 
out before they have attained a normal length. The process 
is progressive, more and more hairs falling prematurely. Each 
new crop of hairs is shorter and finer than the preceding, 
until, finally, only lanugo or short, fine, soft, wooly hairs are 
produced. In the course of time even these are no longer 
produced ; the hair follicles become atrophied, and complete 
baldness ensues. The process is sometimes arrested and nor- 
mal hairs may be produced for a time, but the improvement 
is apt to be transitory. 

This form of alopecia is very common ; it is more frequent 
among men than among women ; as in senile alopecia, it 
ordinarily begins about the vertex and extends towards the 
forehead. 

Symptomatic premature alopecia includes three forms of more 
or less complete baldness, caused by local or general diseases. 



ALOPECIA. 31 

The loss of hair may be temporary or permanent. Fevers, 
nervous disorders, violent shocks to the nervous system and 
mental distress, worry or overwork, may give rise to sudden 
or gradual loss of hair. Local affections, particularly those 
attacking the follicles, as seborrhoea sicca, pityriasis and 
lupus erythematosus, may give rise to baldness, generalized or 
in patches, which may be permanent. When baldness results 
from erysipelas, psoriasis, eczema or variola, the hair is apt 
to return again after the disease has passed away and with 
the recovery of the general health. Syphilis and leprosy also 
occasion alopecia. In syphilis loss of hair occurs in the first 
general outbreak, just as in other fevers ; the hair is then usually 
reproduced. Later in the history of the disease it may occur 
in consequence of local lesions, and when these are ulcerative 
the hair does not grow again. Such cases are rare, and the 
notion that has prevailed in some quarters, that premature 
baldness is the result of syphilis, is absurd, except in the 
limited sense that debauchery may reduce the tone of the 
general system, and thus give occasion to falling of the hair. 
The remedies to be used in alopecia must depend upon the 
exciting cause and the circumstances of the disease. The 
first two forms described are, of course, not amenable to treat- 
ment. Idiopathic premature baldness, when there is a heredi- 
tary tendency to an early fall of the hair, is almost hopeless 
as regards any effect to be produced by medication. When 
there is no history of early baldness in the family, the disease, 
when taken in hand early, can often be arrested in its progress. 
Local stimulation is the plan of treatment to be followed. 
Weekly, semi- weekly, or even daily shampooing may be 
practiced with the soapy wash known as "spiritus saponis 
kalinus" : — 

R. Saponis Viridis giv 

Alcoholis f 3 ij. M. 

Dissolve with heat and filter. 



29 



DISEASES OF THE SKIN. 



This tends to keep the scalp free from the natural accumu- 
lation of sebum and epidermic scales, and likewise stimulates 
the scalp. After shampooing, the scalp is to be thoroughly- 
cleansed with clear water, dried as thoroughly as possible, 
and the following oil is to be applied : — 

K» Acidi Carbolici gr. xv 

Glycerinae f gij 

Aquas Cologniensis ad... f^j. M. 

A good method of applying this oil, so as to get the full 
benefit of it upon the scalp, is to divide the hair in long parts, 
by means of a comb, and then, with the aid of a Barnes' 
dropper, such as is used for dropping solutions into the eye, 
let a drop or so of the oil be placed here and there upon the 
scalp, in the line of the part, at intervals of an inch, and 
well rubbed in with a soft brush like a tooth-brush. Having 
gone over the scalp in one line thus, let new parts be made, 
parallel with the first, and the same procedure gone through 
with. Thus each portion of the scalp is in turn reached by 
the oil, which is thoroughly rubbed into it, a comparatively 
small portion getting into the hair to make a mess, as such 
applications certainly will do if rubbed in at random. 

After a time the shampooing with the soap spirit may be 
dispensed with, or only employed at long intervals, as, in the 
case of women, especially, this is a very troublesome business. 

The inunction with the oil should, however, be persevered 
in until the hair has ceased to fall, or until the case must be 
given up as hopeless. The majority of cases, however, will 
do well under this treatment, if carefully carried out. I 
think that local treatment alone can be relied upon in this 
form of alopecia, but, of course, each case must be judged by 
its total aspect, and the patient's general health cannot be 
left out of account. 

The treatment of that form of alopecia which is, in the 
stricter sense, symptomatic, such, for instance, as is found in 



ALOPECIA AREATA. 33 

nursing women, in students preparing for examination, and 
after exhausting illness or mental troubles, is in general the 
same as that above given, only that here the patient's general 
condition is more obviously at the bottom of the alopecia, 
and attention must first be given to obviating or neutralizing 
the cause. Iron, quinine, arsenic, occasionally cod-liver oil, 
and, above all, nux vomica and strychnia, are the remedies 
on which we chiefly depend. In addition, moreover, to the 
local remedies above given, cold-water douches, frictions, 
frequent brushing and the application of one of the stimulating 
washes to be mentioned under alopecia areata, will be found 
useful. 

The prognosis in premature idiopathic baldness must 
always be guarded. If we can stop the fall of the hair and 
prevent matters getting any worse, that is about all that can 
be expected. To restore what has been already lost is usually 
more than we can succeed in accomplishing. In baldness 
following fevers, etc., on the other hand, much can be hoped 
for as the result of early and vigorous treatment faithfully 
carried out. Syphilitic alopecia, of course, demands specific 
treatment, local means not being neglected. The following 
ointment is useful when distinct syphilitic lesions exist in the 

scalp : — 

$. Hydrarg. Bichlor .• gr. ss 

Tinct. Cantharidis f^j 

Medullae Bovis ^ss 

01. Rosae q. s. M. 

Alopecia Areata (v). Alopecia areata is an atrophic 
disease of the hair system, characterized by the unusually 
sudden appearance of one or more circumscribed, whitish 
bald patches, varying in size and shape, or of more or less 
universal baldness. Alopecia areata may attack any portion 
of the hairy surface, but the scalp is by far the commonest 
seat of the disease. In rare instances the entire hair system 
is involved, and the patient may not only lose the hair from 



34 DISEASES OF THE SKIN. 

the scalp, but that of the eyebrows and lashes, the beard, the 
axilla and pubis, and the fine hairs over the general surface 
of the skin. A number of such cases have come under my 
observation, among others those of a mother and daughter, 
respectively thirty and fifty years of age, both of whom 
showed complete absence of hair from the scalp, pubis and 
axillae, of some years' standing. Upon the scalp the disease 
is usually observed to consist of one or several patches of 
baldness, roundish, sharply circumscribed and conspicuous. 
They may vary in size from a small coin to the palm of the 
hand. The baldness is generally complete, the area present- 
ing a whitish, perfectly smooth, polished surface, often without 
a trace of hair. Less frequently a thin growth of hair persists 
over the nearly bald areas. The skin is slightly or not at all 
altered, excepting that the hair follicles gradually atrophy. 

The course of the disease is variable ; in some instances 
the hair thins out slowly ; in other cases a handful of hair 
may come out in a single night, leaving a fully developed 
patch. The ultimate size of the area is soon reached, and it 
usually grows no larger. When several patches exist they 
usually form one after another, and one may be recovering 
while another is forming. The disease may continue weeks, 
or oftener months ; its course is very variable. Relapses are 
not uncommon. A grow.th of lanugo, or fine, downy hairs, 
often occurs in the course of the disease, leading to the false 
hope that the hair is at length about to return ; but the soft, 
fine hairs drop out again, leaving the patch as bald as before. 
When, however, complete repair once sets in, recovery is 
usually rapid. The new hair is sometimes pale, gray or 
mixed in color. There are no subjective symptoms, as a 
general thing, but patients now and then suffer from neuralgia, 
or notice a premonitory itching or soreness. 

The causes which produce the disease are not understood. 
It is non-parasitic in its nature and is not contagious ; at 



ALOPECIA AREATA. 35 

least that has hitherto been the general belief. The opinion 
is gaining ground, however, that a certain number of cases 
are due to a very minute vegetable parasite. Enough is not 
as yet known to pronounce with certainty upon this point, 
but I think that we are justified in warning patients, particu- 
larly children, against exchanging caps and otherwise coming 
into close contact with those suffering from this affection. 
The majority of cases of alopecia are, in all likelihood, due 
to some functional nerve disturbance, causing impaired nu- 
trition. It has been noted to follow neuralgias, sudden 
nervous shocks, and debility resulting from various causes. 
In many cases, however, patients enjoy excellent health, and 
no appreciable cause for the attack can be assigned. 

Alopecia is more apt to be mistaken for tinea tonsurans 
than for anything else.* The suddenness of the attack, how- 
ever, the more or less complete baldness, the absence of des- 
quamation, the whiteness and remarkable smoothness of the 
patch, always enable it to be distinguished from tinea tonsurans. 
Difficulty can only arise in old cases of tinea, where the short, 
characteristic hairs have disappeared; but even here more or 
less desquamation exists, with a grayish "goose-flesh "-like 
surface, very different from the ivory-like appearance of the 
scalp in alopecia areata. Tinea tonsurans begins as a small 
patch and spreads slowly; there are always, or almost invariably, 
a certain number of nibbled-looking, broken-off hairs in the 
patch, and there is a history of contagion. The microscope 
revealing the characteristic fungus (see under Tinea tonsurans) 
will settle the matter, and should always be employed in cases 
of doubt. 

* There is a form of syphilitic alopecia where the hair falls entirely 
from a segment of the eyebrow. This, which is pathognomonic of syphilis, 
is sometimes the only sign of that disease present, and may be confounded 
with alopecia areata. The occurrence in this locality alone is, however, 
suspicious of syphilis. 



36 DISEASES OF THE SKIN. 

The treatment of alopecia areata should be both internal 
and external. The ordinary tonics — iron, quinine, arsenic 
and nux vomica, or strychnia — are ordinarily to be employed. 
In some cases, phosphorus and cod-liver oil may be given 
with advantage. There are few skin affections where the 
skill of the practitioner in general treatment is more de- 
manded. Often the patient's general health appears to be 
perfect, and only after long and careful search can the weak 
point be found to which the failure in nutritive power is to be 
attributed. Occasionally the minutest examination will fail 
to yield any evidence of disturbance of the normal equi- 
librium of the system. Treatment must then be purely 
empirical. Hygiene is always of importance. 

The external applications which have been found useful, 
or which have been thought to be of use, in alopecia areata, 
are all directed with a view to one single object, namely to 
stimulate the skin and to cause a more active flow of blood 
to the affected parts. Alcohol, cantharides, the essential 
oils, glycerine, castor oil, carbolic acid, tar, iodine, turpen- 
tine, ammonia, salts of mercury, veratria, acetic acid, tannic 
acid, nux vomica, pepper, quinine, sulphur, kerosene oil and 
crude petroleum, are among the remedies usually recom- 
mended as most valuable. These substances may be applied 
either in the form of ointments or of lotions, in sufficient 
strength to produce a stimulant or rubefacient effect, once or 
twice daily, as occasion may require. Before making any of 
these applications it will be well to have the scalp or other 
affected part washed well with castile soap and water or, 
better, with the spiritus saponis kalinus. (See Alopecia?) After 
washing, the scalp is to be dried with a coarse towel, and 
brushed with a thick-set but not too stiff brush, until moder- 
ately stimulated. 

Patients sometimes express the fear that a vigorous appli- 
cation of the external remedy may itself produce baldness to 



ALOPECIA AREATA. 37 

a greater degree, but it will be found that after the patches 
have fairly formed the remaining hairs are firmly seated. 
Among the formulae published in such numbers in books 
and medical journals, those following will be found most 
efficient in the majority of cases : — 

& . Tinct. Cantharidis. 

Tinct. Capsici aa f,l ss 

Olei Amygdala? dulcis fgij 

Aquae Cologniensis f^j. M. 

Wilson recommends the following, which I have sometimes 
used with satisfaction : — 

R. Olei Amygdalae dulcis f # -|j 

Liquoris Ammonias fort f t ^j 

Spiritus Rosmarini f^.v 

Olei Limonis f gj. M. 

Wilson also recommends frictions with a liniment of 
aconite, etc. : — 

R . Tinct. Aconiti rad f^iv 

Chloroformi f 3 ij 

Liquor Ammoniae f 3 j 

Pulv. Camphorae gj 

Olei Olivae f ^ vij. M. 

Oil of turpentine, brushed or rubbed into the patches with 
a stiff brush, once or twice a day, until the scalp becomes 
sensitive, is recommended by some writers. The late Till- 
bury Fox recommended the following, which I have used 
more frequently and with more satisfaction than other prepa- 
rations : — 

R. Tinct. Nucis Vomicae f ^ ss 

Tinct. Cantharidis f,^ v j 

Glycerinae f^ij 

Aceti Destillatae f£ iss 

Aquae Rosae f^ n j- M. 



38 DISEASES OF THE SKIN. 

When from the number of short, broken hairs around the 
margin of the patches, a parasitic origin of the disease is 
suspected (ringworm of the scalp being carefully excluded), 
officinal sulphur ointment sometimes acts very efficiently. 
Blistering the surface with cantharidal collodion, has some- 
times been tried with success. Electricity also is used in 
some cases with advantage, four to ten cells of the constant 
current battery being used, and the negative pole placed in 
contact with the diseased patch. The treatment of alopecia 
of the beard is essentially the same as that of alopecia of 
the scalp. 

The prognosis of alopecia should be guarded. Sometimes 
recovery takes place in a few months, in other cases it may 
be delayed for years. Now and then the hair is not restored 
at all. As a rule, in young persons the baldness is not 
permanent. Treatment should be persevered in. 

Angioma. (See Ncbvus.) 

Anidrosis (i). Anidrosis is a functional disorder of the 
sweat-glands, consisting in a diminished and insufficient 
secretion of sweat. It sometimes occurs in connection with 
ichthyosis. (See Ichthyosis. ) In rare cases an individual ceases 
to sweat entirely at times. In these cases the health is 
greatly impaired, and much suffering may ensue, especially 
in warm weather. The disease in this form is very rare. 
In the treatment every effort should be made to increase the 
activity of the skin. Hot or cold baths, steam baths and 
frictions may be employed. Pilocarpin would seem to be 
indicated, but I do not know if this remedy has been em- 
ployed as yet. Of course, the general health should be 
looked after. 

Aniline Dyes, skin disease produced by. (See Derma- 
titis.~) 

Anthrax (ii). Anthrax or carbuncle is a hard, more or less 
circumscribed, dark red, painful, deep-seated inflammation of 



ANTHRAX. oy 

the skin and subcutaneous connective tissue, variable as to size, 
terminating in a slough. Carbuncle is usually accompanied 
by a good deal of constitutional disturbance. It is ushered 
in by a chill followed by fever. The skin over the affected 
part becomes hot and painful, and a firm, flat, more or less 
sharply circumscribed inflammation, of a somewhat dusky 
red hue, forms, which is deeply seated in the tissues. It is 
painful, with commonly more or less of a burning sensation. 
The symptoms become gradually more marked during ten 
days to two weeks, when the tissues begin to break down 
and soften, and the skin becomes gangrenous. Perforations 
appear at various points, either filled with tough, yellow, 
fibrous cores, or hollow ; and from these issues a yellow, 
sanious fluid. The surface soon assumes a cribriform or 
sieve-like appearance, which is very characteristic. Unless 
the carbuncle is small the whole skin covering it usually 
sloughs sooner or later, leaving a large open ulcer, healing 
slowly. 

The duration of carbuncle is usually from four to six 
weeks, though its course depends somewhat on the age and 
strength of the patient. It is usually single, and its favorite 
seats are on the back of the neck, shoulders, back and but- 
tocks. It is a serious disease in elderly persons, and when 
extensive is apt to terminate fatally. Boils are apt to appear 
about the borders of carbuncle. The affection sometimes 
occurs in connection with diabetes. 

The causes are, so far as can be conjectured, similar to 
those which give rise to furuncles. The disease is not a group 
of boils, but a much more deeply-seated and serious affection. 

Carbuncle is distinguished from furuncle by its size, flat- 
ness, coarse multiple points of suppuration and extensive 
slough. From erysipelas, which it sometimes resembles in 
its early stages, its circumscribed outline will soon distin- 
guish it. 



40 DISEASES OF THE SKIN. 

The general treatment of carbuncle should be strongly 
supporting. The most nourishing foods and stimulants must 
be freely given. Tincture of iron and quinine are the best 
medicines. The latter should be given in sixteen to twenty- 
five grain doses once daily. Anodynes should be given freely 
when required to procure rest at night. Fresh air and exer- 
cise, when these can be taken, are important factors. When 
the carbuncle is tense and hard, deep, cruciform incisions for 
relief have the sanction of old usage to recommend them. 
The majority of cases, however, according to Sir James 
Paget, do equally well without cutting. Prof. Agnew sug- 
gests painting cantharidal collodion around the carbuncle in 
a broad band, the effect of the blister being to remove the 
tension. Ashhurst strongly recommends compression by means 
of adhesive strips, as in swelled testicle, applying them first 
at the margin and gradually bringing them more and more 
inward, leaving a space at the centre to allow the slough to 
come out. Among dressings, Hebra recommends cloths wrung 
out of cold water, or ice bags, in the early stage. So soon 
as suppuration begins, warm fomentations, poultices, etc., 
are to be used. These tend to relieve the tension of the 
tissues, and hasten the discharge of the slough. The poultices 
are best made with flaxseed meal or corn meal ; they should 
be put on hot and changed frequently. The parts should be 
kept clean, washed frequently with a weak carbolic acid solu- 
tion, and the slough removed as rapidly as possible, so as to 
leave a minimal amount of diseased tissue in contact with the 
springing granulations. When the ulcer begins to granulate 
it must be encouraged to heal. The prognosis should be 
extremely guarded. 

Argyria. (See Chloasma.} 

Army Itch. (See Scabies.) 

Arnica. Skin disease from tincture of. (See Dermatitis.') 

Artificial Eruptions. (See Feigned Eruptions.) 



ATROPHY OF THE SKIN. 41 

Atrophia Cutis. (See Atrophy of Skin.) 

Atrophy of the Skin (v). There are several forms of 
cutaneous atrophy, some of which seem to occur idiopathi- 
cally and without obvious cause, while others are the result 
of some general disorder or of some injury to the nerves. 
In the "glossy skin" of writers upon nervous diseases the 
extremities, especially the fingers, become pinkish or reddish, 
smooth, shining and glossy, as though varnished. The lesions 
resemble chilblains in appearance. The affection is accom- 
panied by burning pain, and follows intractable neuralgia, 
wounds and other lesions of the nerve trunks. 

General idiopathic atrophy of the skin is a very rare con- 
dition, in which the skin becomes dark and discolored in 
patches and swollen, then contracts, becomes of an olive 
color, and seems too small for the body. The sensibility of 
the skin is deadened and the movements of the body effected 
with difficulty. 

The disease described as "Xeroderma of Hebra" is a 
form of diffuse idiopathic atrophy of the skin. The skin in 
this form of the disease becomes thin and lightly stretched, 
dry as parchment and wrinkled. In places it is white and 
without pigment, while elsewhere it is abundantly dotted over 
with disseminated punctiform or lentil-shaped, yellowish or 
dark brown, pigmented spots, resembling those of freckles, 
giving the skin a remarkable chequered appearance. Here 
and there are bright red telangiectases. 

Another form of atrophy of the skin is that known as 
"atrophic lines and spots." This form of atrophy may also 
be idiopathic or symptomatic. In the first case it comes 
without apparent cause, the patient's attention often being 
attracted to the lesions only by accident, and after they have 
existed for some time. The lines (stria atrophica) are usually 
an eighth to one-quarter of an inch in diameter, and one to 
several inches in length ; the spots (macula atrophica) are 
4 



42 DISEASES OF THE SKIN. 

roundish or ovalish, and from a pin-head to a pea or finger- 
nail size. Both lesions present a smooth, glistening, scar-like 
appearance, are perceptibly thinned to the touch, slightly 
depressed or grooved, and show a peculiar mother-of-pearl 
lustre. The lines are usually found in numbers running par- 
allel to one another, and in an oblique direction. The spots 
are generally isolated. They may occur on any part of the 
body, but are usually found on the buttocks, trochanters, 
pelvis, and on the thighs, upon both extensor and flexor 
surfaces. They run a slow course, and give rise to no incon- 
venience. Their course is obscure ; they are sometimes found 
in connection with morphcea. (See Morphea?) 

Symptomatic lines and spots of an atrophic character are 
those formed by stretching of the connective tissue bundles, 
as seen on the skin of the abdomen in pregnancy, etc. (See 
Hemiatrophia facialis?) 

Atrophy of the Hair (v). Symptomatic atrophy of the 
hair may be the result of pityriasis and the parasitic diseases 
of the scalp, and also of syphilis, fevers, etc. The hairs 
diminish in size, become dry and brittle, and tend to split up 
and separate. Idiopathic atrophy of the hair, a rare condition, 
manifests itself in several forms which have been described of 
late years. We have Fragilitas crinium, when the hair is 
thinner in one part of its shaft than another, while the free 
ends tend to split into filaments. Duhring has described one 
form of this affection where the hair splits in its length, sepa- 
rating within the hair follicle and giving rise to irritation. 
Another form of atrophy of the hair is that known as Trick- 
orexis nodosa, which consists in the formation of a series of 
small, spindle-shaped, bulbous swellings, situated at irregular 
intervals along the shaft of the hair, and looking like the ova 
of pediculi. The hair breaks at these bulbous points, leaving 
a brush-like extremity of ragged filaments. A somewhat 
similar disease is Piedra, which is met with in South America, 



BED-BUG. 43 

in which hard, gritty particles, visible to the eye, are found 
surrounding or attached to one side of the hair, at short 
intervals. These forms of disease are, some of them, more 
frequently found on the scalp, others in the beard. Constant 
shaving is the treatment which seems to do most good. 

Atrophy of the Nail (v). Atrophy of the nail is an 
affection scarcely worthy of note, were it not for the fact that 
it may be mistaken for affections of a more important nature, 
clinically and therapeutically, as the parasitic diseases of the 
nail. The nail is usually smaller and thinner than normal ; 
or brittle and split ; or soft and crumbly — according to the 
cause. The color may be pale, whitish, opaque or dark. The 
so-called "worm-eaten" condition of the nail, due to various 
causes, is generally an atrophy. Injuries, syphilis, eczema, 
psoriasis and fungous disease may attack the nail, and are to 
be distinguished from idiopathic atrophy. The remedies ap- 
propriate to these diseases elsewhere will generally cure them 
when they attack the nail, but idiopathic atrophy is almost, 
if not quite, incurable by any means at present known. I 
have sometimes thought that arsenic, in the form of four- 
minim doses of Fowler's solution, has been useful, and would 
suggest the further trial of this remedy. 

Baldness. (See Alopecia?) 

Barbadoes Leg. (See Elephantiasis. ~) 

Bakers' Itch. (See Eczema of the hands.) 

Barbers' Itch. (See Tinea sycosis.) 

Bed-bug. This insect is occasionally the cause of an 
urticaria-like eruption on the skin, which is liable to be mis- 
taken for other diseases. The lesion produced by its bite is 
of the nature of an urticarial wheal, consisting of a circum- 
scribed, slightly raised, split-pea sized erythematous spot, 
with a whitish centre, and at times attended with considerable 
swelling. A reddish blood spot, or hemorrhage, under the 
skin remains after the wheal has subsided. The sensation is 



44 DISEASES OF THE SKIN. 

at first of a very slight prick, followed in a few minutes by 
burning and itching. In children the disease is often taken 
for " hives" or "nettlerash" (urticaria). The bites of the bed- 
bug may be relieved by lotions containing alcohol, carbolic 
acid, vinegar, dilute acetic acid, corrosive sublimate, lead 
water, spirits of hartshorn, etc., sponged upon the parts. 
The best preventive against bugs in beds and other haunts 
is solution of corrosive sublimate. Pyrethrum powder is also 
useful. 

Bloody Sweat. (See Purpura.') 

Body Louse. (See Pediculosis corporis.) 

Boil. (See Furuncle.) 

Bromidrosis (i). Bromidrosis is a functional disorder 
of the sweat glands, characterized by more or less sweating 
and an offensive odor. The affection may be local (it usually 
occurs on the soles), or general. The odor may be of a 
general disagreeable character or it may be distinctive, re- 
sembling the smell of a goat or of urine. Cases have been 
reported where an odor resembling that of violets or pine- 
apple has been exhaled during attacks of hysteria, anger 
or sexual excitement. The treatment is that of hyperi- 
drosis. (See Hyperidrosis.) Salicylate of sodium, in five- 
grain doses, has proved useful in cases depending on nervous 
excitement. 

Bromine Eruption. (See Dermatitis Medicamentosa^) 

Callositas (iv). Callosities are those hard, thickened, 
horny patches of skin, of variable size and shape, grayish 
or yellowish in color, unattended by pain, and which occur 
for the most part about the hands and feet. They are com- 
posed of an increased quantity or growth of the epidermic 
layer of the skin. They commonly occur at some point 
where the occupation of the individual gives occasion to 
unusual pressure and friction, so that in many cases the 
profession of the patient can be surmised from the locality 



CANITIES. 45 

of the thickening. Occasionally, however, they appear to 
occur spontaneously. 

When the callosity causes pain or inconvenience, it is to 
be removed by means of local measures. The part should 
be soaked repeatedly in warm water, or macerated by a water 
dressing or a poultice, and when it is softened, it may be 
scraped or pared off, layer by layer, by means of a sharp 
knife. A plaster of india rubber containing salicylic acid 
has also been recommended in severe cases. 

Cancer of the Skin. (See Carcinoma, Epithelioma and 
Sarcoma. ) 

Canities. Graying or whitening of the hair. It may be 
senile or premature. Premature graying of the hair may 
occur under a variety of circumstances, and may be partial 
or universal. It rarely takes place before adult life. Usually 
when the hairs have once turned gray they remain so, but 
sometimes recover their color. Occasionally, the hair is 
found to turn gray in winter and dark in summer. The hair 
may turn gray after severe illness, after injuries or diseases of 
the nerves, or after ligation of the carotid. In one case coming 
under my care, a woman with red hair lost it almost entirely, 
from alopecia areata. As the hair began to come back, after 
some months' treatment, it was at first quite gray, but after- 
wards recovered its color. In a case of lupus erythematosus 
of the scalp, under my care for several years, the hair, which 
was absent entirely while the disease was present, began to 
return as the patient recovered, but instead of being brown as 
before, was found to be of a dark gray tint. The question as 
to whether the hair may turn suddenly gray, in a single night, 
for instance, has been much discussed. I think a sufficient 
number of authentic cases have been published to prove 
that this can certainly occur. Internal remedies have no 
effect in restoring the color of the hair. Dyeing is the only 
resort. 



46 DISEASES OF THE SKIN. 

Carbuncle. (See Anthrax?) 

Carcinoma (vi). The commonest form of cancer of the 
skin is epithelioma, and under this head will be found a 
description of the various forms of this variety of cancer. 

The other varieties of primary or secondary cancer of the 
skin are the following: i. Carcinoma lenticulare ("scir- 
rhous," "hard," "fibrous" or " connective tissue" cancer); 
characterized by smooth, glistening, dull pinkish or brownish 
red, flat or raised papules, tubercles or nodules, from pea to 
bean, or larger size, disseminate, at first separate, later run- 
ning together, slow in its course, involving the neighboring 
glands, causing pain, breaking down, recurring on excision 
and ending fatally. 2. il Carcinoma tuberosmn /" a rare 
affection, occurring in flat or raised, rounded or ovalish, 
tubercular or nodular lesions, from pea to walnut size or 
larger ; firm, hard, deeply imbedded in the skin and the sub- 
cutaneous connective tissue, of a dull reddish, brownish red 
or violaceous color, multiple, disseminated, or irregularly 
grouped, sooner or later breaking down into ulcers and 
ending fatally. 3. Carcinoma melanodes or pigmentodes ; 
beginning in the form of multiple, small, pin-head, pea- or 
bean-sized, rounded or ovalish, soft or firm papules, tuber- 
cles or nodules, of an iron-gray, brownish, bluish black or 
blackish color, at first discrete, but tending to aggregate into 
tumor masses, and then to break down and ulcerate, forming 
often fungous, gangrenous and pultaceous masses, commonly 
found starting in a mole or wart on the face or on the hands 
and feet, usually encountered in early adult or middle life, 
and pursuing a malignant course. 

The treatment of these forms of cancer, when early seen, is 
essentially the same as that described under epithelioma and 
sarcoma. Later they necessarily fall under the care of the 
surgeon. 

Chaps. (See Eczema, fissum and of hands.-) 



CHLOASMA. 47 

Cheiro-pompholyx. (See Dysidrosis.) 

Chilblain. (See Dermatitis eonge/ationis.) 

Chloasma (iv). Chloasma, sometimes called "melano- 
derma," is a discoloration of the skin, occurring in variously- 
sized and shaped patches, of a yellowish, brownish or blackish 
tint. It may occur over a part or over the entire surface, 
and may be idiopathic, the result of external agencies, as 
scratching, blistering and heat, or symptomatic. Belonging 
to the latter category may be mentioned chloasma uterinum, 
the pigmentation of Addison's disease, and those discolora- 
tions which occur in connection with certain general diseases, 
as tuberculosis, cancer, malaria, etc. 

The most important variety of chloasma is chloasma uteri- 
num, which consists in the presence of one or several patches 
of pigment deposit, appearing usually about the forehead, 
extending across from side to side, from below the base of 
the scalp to just above the eyebrows, in a broken or con- 
tinuous band. Occasionally the whole face may be covered, 
as with a mask. The discoloration may also occur elsewhere 
on the body. The affection occurs between puberty and 
middle age, is more frequent in married women, and is caused 
by pregnancy or by uterine derangements. In single women 
it generally occurs between the ages of thirty and forty, and 
does not show itself after the climacteric period, either in the 
single or in the married. 

Chloasma is apt to be mistaken for tinea versicolor, on 
account of the similarity in color. The distribution of the 
disease is, however, quite different (see Tinea versicolo?-), and 
the presence or absence of the fungus always found in the 
latter disease on microscopic examination will settle the 
question. The treatment of chloasma should first be directed 
to the removal of the cause, when this is possible. Without 
this all external treatment is apt to be disappointing. The 
discoloration may be removed from the skin temporarily, by 



48 DISEASES OF THE SKIN. 

means of certain washes which cause desquamation of the 
superficial layers of the epidermis. These must be used at 
first with some caution, to prevent a too severe action upon 
the skin. The following formulae may be suggested: — 

R. Hydrarg. Chlor. Corrosiv gr. vss 

Zinci Sulphatis 

Plumbi Subacetatis aa... gss 

' Aquae f ^ iv. M. 

Sig. — Lotion. Apply morning and evening. 

Here is a formula recommended by Bulkley: — 

R. Hydrarg. Chlor. Corrosiv... gr. vj 

Acidi Acetici Diluti f^ij 

Boracis ^ IJ 

Aquae Rosae ^3 lv - M. 

Sig. — Lotion. To be applied night and morning. At first this may be 
gently brushed over the affected parts, which may afterwards be rubbed 
well with it. If the skin becomes too scaly this application should be 
suspended for a day or two, and sweet cream should be applied. 

Recently this ointment has been recommended : — 

R. Hydrarg. Pur gr. c 

Ung. Hydrarg., 

Sevi. Benzoinati aa gr. c 

Adipis Benzoinati ad £iv. M. 

Spread upon muslin and bind on patches at night, or rub in thoroughly 
with the finger. 

During the day the following paste is to be spread thinly 
over the affected parts : — 

B . Bismuthi Oxychlorati, 
Amyli Oryzae, 
Kaolini.... : aa gr. 1 

Ung. Glycerinae (Ph.G.), oth- 
erwise Glycerite of Starch, ^iv. M. 

Argyria is a form of discoloration of the skin occurring 
after the prolonged use of nitrate of silver. Iodide of po- 



CLAVUS. 49 

tassium, in the average dose, has been employed successfully 
in two cases of this condition. 

Nczvus pigme?itosus, or pigmentary mole, may be of various 
size and shape, with a soft and smooth, or an uneven and 
rough, surface; or it may occur in the form of thick, soft, 
fatty, connective tissue growths. Sometimes hairs are found 
growing from it. Pigmentary nsevi may be single or multiple. 
They may occur in the course of nerve tracts, or, more fre- 
quently, irregularly scattered over the surface. They may be 
removed by means of the knife, or with caustics ; when they 
are small and flat they may be operated upon with caustic 
potash or ethylate of sodium. Sometimes patients desire the 
hairs to be removed from hairy moles of the face without 
caring to undergo an operation for the entire growth. In 
such cases recourse may be had to electrolysis (see Hirsuties) 
with a very satisfactory result. The small scar caused by 
the removal of the hair tends to lighten up the color of the 
mole. 

Chromidrosis (i) shows itself in the excessive secretion 
of variously colored sweat, which may be bluish, blackish, 
reddish, greenish or yellowish. It is apt to be intermittent. 
It is so rare as to be a curiosity rather than a disease. As- 
tringent applications are indicated. (See Hyperidrosis.~) 

Clavus (iv). Clavus or corn is a small, circumscribed, 
usually flat, deep-seated, more or less horny formation, pain- 
ful upon pressure, situated for the most part about the toes. 
Like the callosity, it is the result of pressure, and this, if 
continued, may give rise to inflammation. The common seat 
of the corn is the outer seat of the little toe and the tops of 
the toes. Occurring between the latter, the corn is accom- 
panied by more or less maceration, and is known asa" soft" 
corn. The cause of corns is to be found in ill-fitting or too 
tight shoes. The growth is made up of a circumscribed, 
excessive development of the epidermis, and of a central 



50 DISEASES OF THE SKIN. 

portion or core. The latter extends quite deeply into the 
tissues, in the form of an inverted cone, the base being 
directed outwards, and appearing on the surface as a rounded 
spot. The apex of the corn rests on the papillary layer of 
the corium. The pain attending corns is produced by the 
core pressing upon the true skin, causing irritation of the 
nerve filaments of the papillae. 

The first principle in the treatment of corns is the removal 
of the cause. Tight or badly-fitting shoes must be changed 
for others or modified in shape. The next point is the re- 
moval of the mass of epidermis. The professional chiropo- 
dist prefers to do this while the corn is dry, because its limits 
are better defined. Most persons, however, will object to 
the pain this is apt to cause, and I think it better, as a gene- 
ral thing, to first soften the epidermis by means of a poultice, 
or by covering the corn with a bit of patent lint, soaked in 
solution of sodium carbonate, and covered with a piece of 
oil silk or wax paper. The outer layers being thus macerated, 
may be removed by picking or scraping them with a sharp 
knife ; care being taken not to penetrate and wound the 
sensitive tissues. The corn should be protected from pressure 
by a plaster, as the " emplastrum fuscum" : — 

R. Plumbi Oxidi Rubri giv 

Olei Olivarum f^j 

Cerse Flavas gij 

Pulv. Camphorse gr. x. M. 

Boil the lead oxide and the oil together until a brownish-black mass is 
formed ; then add the other ingredients, while still hot. 

Or diachylon plasters maybe used. They should be spread 
upon soft leather or chamois, and have a hole cut in the 
centre. The corn plasters in felt, of ring shape, which 
may be procured in the shops, answer an excellent purpose. 
Corns which have become inflamed must be cared for assid u- 
ously, or they are likely to give much trouble. Perfect rest, 



COMEDO. 51 

for a time at least, is required in these cases, and some sooth- 
ing application. Poultices of bread crumbs and dilute lead 
water, applied cold, exercise a powerful sedative action. Soft 
corns are best treated by excision,- when this is possible. 
Nitrate of silver in solid stick, glacial acetic acid, flexible 
collodion, powdered oxide of zinc or tannic acid, are all 
useful. The toes should be separated by a thin layer of 
raw cotton. 

Comedo (i). Comedo is a disorder of the sebaceous 
glands, characterized by yellowish or whitish, pin-head size 
elevations, containing in their centre blackish points. It is 
observed chiefly about the face, neck, chest and back. Each 
single elevation is called a comedo (plural comedones). The 
common name, " flesh- worms" or "grubs," is calculated to 
convey the erroneous idea that the small inspissated plug of 
altered sebum which can be expressed from the follicle is a 
parasitic worm. It is true that a little mite, the microscopic 
Demodex folliculorum, is occasionally found in the mass, but 
this cannot be regarded as in any way essentially connected 
with the disease. Its presence is merely fortuitous and with- 
out significance, the plug consisting of altered sebaceous 
matter, mingled with epithelial cells. The affection, though 
comparatively trifling, and without subjective symptoms, is 
often extremely annoying to patients. It is due in part to 
idiosyncrasy, in part to a general sluggish performance, not 
only of the functions of the skin, but also of those of the 
whole body. Patients are apt to suffer from dyspepsia with 
constipation. In young women chlorosis and menstrual 
difficulties are apt to be present. The disease is pre- 
eminently one of the period of puberty; patients seeking 
relief from this complaint are almost invariably young men 
and young women, although the disease may occur in infants 
and young children. 

Local treatment suffices in most cases to relieve the con- 



52 DISEASES OF THE SKIN. 

dition. Frequent bathing of the affected surface with hot 
water will aid this process of removal. Stimulating oint- 
ments, especially such as contain sulphur, are useful, as the 
following: — 

R. Sulphur. Prsecipitat ^j 

Ung. Aquae Rosse ^j. M. 

Sig. — To be rubbed in at night. 

Sulphur lotions, such as those given under the head of 
acne, may also be useful. Should the skin tend to become 
harsh under the use of these remedies, weak alkaline oint- 
ments may be used for a time, as this :— 

]J. Sodii Bi-borat ^ss 

Glycerine ttb xv j 

Ung. Aq. Rosse ^j. M. 

An excellent application is the following: — 

R. Aceti spj 

Glycerinse £iij 

Kaolini giv. M. 

This forms a soft paste, which is to be spread over the surface 
at night, and, if possible, in the morning also. If applied 
on the face, the eyes should be kept shut, on account of the 
pungency of the vinegar. It loosens and dislodges the seba- 
ceous plugs more satisfactorily than any other preparation 
with which I am acquainted. A watch-key may be employed 
to press out the comedones, the end being gently but firmly 
pressed down over the sebaceous plug. Should this not yield 
readily, the point of a fine needle may be run into the follicle, 
alongside of the comedo, and then moved around, so as to 
loosen and detach the plug from its surrounding wall. Care 
should be taken not to use too much force, for fear of inflam- 
ing the skin. If the comedo plug does not come out easily, 
it should be left for another time. It must be remembered, 
that so long as the condition which produces comedo is 



CORNU CUTANEUM. 53 

present and effective, the comedones are apt to be reproduced. 
Several in succession may have to be removed from the same 
glandular opening. 

Occasionally the contents of the sebaceous follicles become 
even more condensed and hardened than above described. 
The firm, almost horn-like plugs are gradually forced out of 
the mouth of the follicles, until they may stand up stiffly 
above the surface of the skin. Such a case came under my 
notice years ago, the skin of the trunk, particularly over the 
shoulders, being the seat of the disease. The hardened 
sebaceous plugs, in great numbers, projected to the height of 
an eighth to a quarter of an inch, giving the surface of the 
skin a nutmeg-grater appearance, viewed from a little dis- 
tance. Hot baths, frictions with saponis viridis and in- 
unction of officinal sulphur ointment, may be used in such 
cases. 

Condyloma. (See Verucca.') The name of "condy- 
loma lata," or " flat condyloma," has sometimes been given 
to the moist syphilitic papule. This term leads to confusion, 
and has been mostly dropped by modern writers. There is 
but one condyloma, which has nothing syphilitic about it, 
although it may occur on a syphilitic patient, just as he might 
have an ordinary wart on the finger. 

Corns. (See C/avus.) 

Cornu Cutaneum (iv). Cutaneous horns are hypertrophic 
growths or excrescences of the skin, which, when fully de- 
veloped, differ slightly, if at all, in structure, from those 
found normally in the lower animals. They are solid, hard, 
dry and wrinkled, or laminated. In form the growth is 
usually elongated and roundish or conical ; sometimes it 
assumes a flattened or button-like form. The horn is often 
twisted and misshapen. The color varies through gray to 
black, or it may be yellowish or brownish. Horns may be 
of any size from that of a pin's head to that of the finger. 



54 DISEASES OF THE SKIN. 

The base is concave or flattened, and rises from the skin, 
which may be normal or inflamed. Horns are usually single, 
but may be multiple. They may occur upon any part of the 
body, but are common upon the face. A case has been re- 
ported where a horn of considerable size grew from the fore- 
skin of the penis. Though commonly occurring upon 
elderly people, they are also found in the young. They are 
painless when not injured, and grow slowly, dropping off at 
times when they have reached considerable size, and leaving 
behind a shallow ulcer from which the horn is again repro- 
duced. 

The treatment of cutaneous horn is simple. The growth 
is to be twisted or cut out, and the base cauterized with 
caustic potassa or chloride of zinc, to prevent its reproduction. 

Crab Louse. (See Pediculosis. ,) 

Crusta Lactea. (See Eczema.} 

Cyst. (See Sebaceous cyst.) 

Dandriff. (See Pityriasis capitis.) 

Dermatitis (ii). Under this head are grouped a number 
of inflammatory diseases of the skin, which the insufficiency 
of our present classification does not permit to be placed 
elsewhere. The lesions vary in the different affections classed 
under dermatitis. In some, erythema of various grades exists ; 
in others, vesicles, pustules, blebs or gangrene may present 
themselves. According to the causes producing this form 
of inflammation of the skin, we may have: i. Dermatitis 
traumatica. 2. Dermatitis venenata. 3. Dermatitis con- 
ge lationis. \. Dermatitis caloric a. 5. Dermatitis gangrenosa. 
6. Dermatitis medicamentosa. 

Dermatitis Traumatica. This is due to violence to the 
skin. Under this head are included abrasions, contusions, 
excoriations depending upon scratching, etc. 

Dermatitis Venenata. This is produced by poison oak 
and ivy, poisonous sumac, nettle, mezereon, arnica, etc., and 



DERMATITIS VENENATA. 55 

is one of the most important of these forms of dermatitis, on 
account of its common occurrence, and the pain and annoy- 
ance to which it gives rise. It prevails chiefly in the Spring 
and Autumn, and varies much in intensity in different parts 
of the country, occurring in a severe form in California, for 
instance. Personal idiosyncrasy likewise plays an important 
part. An exposure to direct contact with the poison vine, or 
oak, may be endured by one person with impunity, while 
another, susceptible to the influence of the rhus, may be 
severely attacked as a result of exposure to the smoke, alone, 
of the burning vines, or even to the wind blowing over the 
fresh ones. The poison is readily conveyed from the hands, 
the usual point of first contagion, to the face and genitalia, 
which are very apt to become the seat of the disease, also. 
The eruption usually follows exposure within a few hours. It 
may be erythematous or vesicular, but is usually the latter. 
The vesicles may be few in number and ill-developed, or they 
may be numerous, of various sizes, crowded together and 
seated on an inflamed or cedematous base. Swelling, heat 
and itching are among the most marked symptoms. Some- 
times the parts attacked, as the face, are much swollen and 
disfigured. The lesions run an acute course, usually ruptur- 
ing and drying into yellowish crusts. The affection may last 
from one to six weeks. In persons predisposed to eczema, 
an attack of this affection may follow. This should be borne 
in mind in giving a prognosis. 

Local treatment is alone usually required. Of the in- 
numerable remedies recommended from time to time in the 
medical journals, the majority owe their reputation to their 
success in curing isolated cases. In a disease like dermatitis 
venenata, which is so often self limited, a few cases success- 
fully treated forms an insufficient basis for the recommenda- 
tion of a new remedy. Fortunately there are a sufficient 
number of well-tried old remedies which are sufficient for a 



56 DISEASES OF THE SKIN. 

cure in every case. These are for the most part sedatives 
and astringents. Dilute lead water is popular and useful. 
Black wash may be employed as a lotion, and sopped on the 
affected parts for a quarter of an hour at a time, every three 
or four hours during the day ; to be followed by this oint- 
ment at night : — 

R. Acid Carbolic gr. x-xx 

Ung. Aquae Rosse ^j 

Hydrarg. Chlor. Mite gr. x. M. 

Decoction of white oak bark is also useful. The follow- 
ing, recommended by Hardaway, of St. Louis, has done me 
good service : — 

R. Zinci Sulphat ^ss 

Aquas Oj. M. 

SiG. — Apply on cloths every hour through the day, and several times 
during the night. 

The remedy, however, which I have used almost exclu- 
sively for the past five or six years, is the fluid extract of 
grindelia robusta : — 

R. Ext. Grindelise Robustae, fl'd.. f^ij 

Aquae f!§j. M. 

This is to be applied to the affected parts on cloths, which 
are to be thoroughly wet with the solution and then allowed 
to dry almost completely upon the skin, removing them when 
nearly dry and renewing the application, but not keeping the 
cloths constantly sopping wet, as with other sedative and 
astringent lotions. 

Astringent powders may also, at times, find appropriate 
place, as on the face, when the patient is obliged to go 
about and cannot keep wet cloths, etc., applied. The fol- 
lowing may be mentioned : — 

R. Pul vis Zinci Carb. Praecip., 

Amyli Oryzae aa 3 j. M. 



Or this, 



DERMATITIS CONGELATIONIS. 57 



R . Magnesii Carbonatis Levis, 

Pulveris Lycopodii M ^ss. M. 



Akin to Dermatitis venenata is that form of inflammation 
of the skin which is brought about by the use of poisonous 
clothing. Stockings or underclothing dyed with aniline red, 
yellow or brown morocco hat bands or shoe linings, or green 
tulle dresses, are among the forms of clothing most likely to 
give rise to dermatitis. Tincture of arnica and other medi- 
cinal agents sometimes give rise to dermatitis, and advantage 
is sometimes taken of the action of these remedies to produce 
feigned eruptions. (Set Feigned Eruptions.} 

Dermatitis Congelationis. " Chilblain." The inflam- 
mations of the skin produced by cold resemble in many 
respects those produced by heat, only, unlike burns, their 
course is slow. In addition, a certain morbid predisposition 
on the part of the patient is a necessary condition of their 
occurrence. The occurrence of chilblains does not neces- 
sarily depend on the influence of extreme cold ; indeed, the 
affection is commoner in hot than in cold countries, and 
may occur at a temperature not below 32 F. Anaemic and 
chlorotic persons are more apt to be the subject of the 
affection. 

The erythematous form of chilblain shows itself in the 
form of circumscribed patches, of a livid red color and 
somewhat tubercular character, the color disappearing under 
pressure of the finger. The lesions itch and burn painfully. 
They occur most commonly upon the fingers and toes, but 
may appear also on the ears, nose, or other parts of the face, 
or indeed on any part of the body which is exposed to cold. 
Their course is essentially chronic ; usually they do not 
change in appearance, but sometimes become hard and in- 
filtrated, while at other times, under the influence of pressure 
or rubbing, as of the shoe, or of scratching, a bleb or pustule 
5 



58 DISEASES OF THE SKIN. 

forms. The pain is then considerably increased, especially 
when the bulla or pustule bursts and leaves an ulcer. 
These changes, however, frequently lead to the cure of 
the affection, which might otherwise have lingered on 
indefinitely. 

The bullous form of chilblain is formed under the influ- 
ence of a more intense degree of cold, and is characterized 
by the formation of watery or sero-sanguinolent blebs, the 
size of hazel-nuts or goose-eggs. If they are not punctured 
they undergo no change for some time, but at last break, 
after having effected considerable destruction of tissue, the 
bones even of the feet and hands being occasionally laid 
bare and exfoliating. 

The escharotic chilblain is simply a still more extreme 
degree of the same process, sloughs forming, which may be 
cast off without further effect, or which may poison the blood 
with fatal effect. 

The treatment of chilblain is, first of all, in the way of 
prevention. A sufferer from this disease must not expect 
to be cured while continuing to expose himself to the in- 
fluences which produced it. Warm and sufficient clothing, 
protection of the hands and feet, and in cases where the 
general system is below par, such medication and hygiene as 
will improve this condition, such are the points to which 
attention must first be paid. In mild acute chilblain, rest, in 
the horizontal position, frictions with cold water or snow, 
and astringent sedative lotions, as lead water, lotion of 
grindelia robusta (see Dermatitis venenata) , or opiate washes, 
may be prescribed. In the more chronic forms of erythema- 
tous chilblain stimulant applications are called for. When 
unbroken the lesions may be painted with tincture of iodine, 
or better, with oil of peppermint, pure or mixed with one to 
six parts of glycerine. The following pigment is convenient 
of application : — 



DERMATITIS GANGRENOSA. 59 

R. Tinct. Iodini ]}j 

yEtheris f^iiss 

Collodii f|j. M. 

Sig. — Apply with a camel's hair brush. 

When the lesions are broken, or in any case, this paint 
following forms an excellent application : — 

R. Terebinth. Venetian giij 

Ol. Ricini f^iss 

Collodii f^viiss. M. 

SiG. — Apply with a brush as often as required to shield the chilblain 
from the air. 

The following ointment may also be employed : — 

R. Plumbi Acetat giiss 

01. Rapi (Colza) f^j 

Vitel. Ovi j 

Cerae Flavse 3^ iss. M. 

Carbolized cosmoline relieves the burning and itching. 

The severer forms of dermatitis from cold belong rather 
to the province of the surgeon than the physician. When 
operative interference is not demanded, they are to be treated 
in a similar manner to burns of the like gravity. 

Dermatitis Calorica. This subdivision includes the 
inflammatory symptoms produced by heat, in the form of 
burns. The treatment of such lesions ordinarily comes under 
the management of the surgeon, and need not therefore be 
referred to further. 

Dermatitis Gangrenosa is a rare affection which has 
chiefly come into notice during the past few years, through a 
number of reports of cases published in the medical journals. It 
may be idiopathic or symptomatic. The idiopathic form is apt 
to occur symmetrically. It usually begins in the form of small or 
large, circular, erythematous, reddish or purplish spots, which 
may be tender and painful, or without sensation ; after under- 
going a more or less variable course they become gangrenous 



60 DISEASES OF THE SKIN. 

and slough, the process terminating fatally or in recovery ; 
the latter event taking place sometimes in the gravest cases. 
There is usually some constitutional disturbance, fever, malaise 
debility, etc. Gangrenous patches may follow nerve lesions, 
or may occur, also, in connection with grave cerebral or 
spinal diseases, as in the form of acute bed-sore. These form 
the symptomatic form of gangrene. I have seen a case where 
a man who had recently suffered amputation of a leg, for a 
railroad accident, showed, within a week, lesions over the 
knuckles and on the right forearm, resembling at first a bullous 
erythema, and changing later to black sloughs, which were 
finally thrown off by ulceration. 

In all cases of gangrene of the skin, and the like, care 
should be taken to exclude artificial and feigned diseases. 

Dermatitis Herpetiformis (Duhring) is a rare disease, 
characterized by the formation of erythematous patches of 
an urticarial or erythema-multiforme-like character, herpetic 
vesicles, blebs, pustules, flat or acuminate, whitish in color, 
with a more or less inflammatory base, and papules, 
accompanied by violent itching. One or another of these 
various lesions may appear alone, or one may succeed 
another, or they may all occur together. This is the 
peculiarity of the disease, that sometimes it looks like 
herpes, sometimes like pemphigus, sometimes like urticaria 
or erythema, sometimes like pustular eczema or impetigo, 
and now and then, like all together. The lesions are apt 
to occur in clusters. 

A variable amount of constitutional disturbance is present, 
especially with each new outbreak. The disease comes out 
in crops, tends strongly to relapse, and may run along for 
years. It occurs in both sexes, but is most often met with in 
the parturient state, and is a serious disease, the pustular 
variety being especially grave. It is very rebellious to treat- 
ment. It is a neurotic manifestation. 



DERMATITIS MEDICAMENTOSA. 61 

The treatment must be directed, on general principles, to 
suit each case ; no specific measures can be recommended. 

Dermatitis Medicamentosa. Affections of the skin 
due to the ingestion of medicinal agents, are mostly of two 
classes, either a diffuse, erythematous, papular or petechial 
eruption, or an involvement of the glands, with the formation 
of pustules, furuncular or phlegmonous lesions. The drugs 
thus far known to have given rise to eruptions of the skin are 
as follows : Arsenic may give rise to dermatitis of an erysipe- 
latous type, papular, urticariaform, vesicular and herpetiform 
eruptions. Pustular and furuncular eruptions are also said to 
have been observed. Belladonna gives rise at times to an 
erythematous or scarlatiniform, and sometimes to an erythe- 
mato-papular rash. Bromine, or rather its salts, give occa- 
sion to the occurrence of maculo-papular, pustular or phleg- 
monous eruptions. Cannabis Indica has been known to cause 
a vesicular eruption. Chloral may give rise to an erythema- 
tous condition of the skin, or to papular, urticariaform, 
vesicular, pustular, and now and then to more or less severe 
petechial eruption. Copaiba commonly gives rise to an ery- 
thematous or roseolaform eruption. Bullous eruptions have 
also been reported as due to this drug. Cubebs has been 
reported as causing a roseolaform eruption, and Digitalis a 
scarlatiniform eruption, with papular, erythematous lesions. 
Iodine alone, or in combination, often causes the appearance 
of eruptions of the skin, of which the form may be erythe- 
matous, papular, vesicular, bullous, pustular or hemorrhagic. 
Of these the pustular is the commonest, and, in its acneform 
variety, the best known. Occasionally it may assume a 
phlegmonous aspect, resembling some syphilitic eruptions. 
Mercury commonly gives rise to erythematous and scarlatini- 
form eruptions, though cases have been described where 
vesicles, bullae, pustules and phlegmon have been observed. 
Morphia or opium usually gives occasion to a scarlatiniform 



62 DISEASES OF THE SKIN. 

rash, which attacks the flexor surfaces by preference, and is 
sometimes followed by extensive desquamation. Phosphoric 
acid is reported in one instance to have given rise to a 
bullous eruption. Quinine and Cinchona now and then give 
occasion to the appearance of very striking eruptions, resem- 
bling the rash of scarlatina or measles, occasionally papular, 
urticariaform, hemorrhagic, or even gangrenous eruptions 
are found to follow the ingestion of these drugs. Salicylic 
acid now and then produces a scarlatiniform eruption, and 
cases have been reported where vesicular and petechial erup- 
tions have followed its use. Santonine and strychnia have 
been reported in single instances as producing eruptions, as 
also have tar, carbolic acid, turpentine, rosin and petroleum. 
Other drugs are being added to the list, from time to time, 
as our knowledge and observation of the effects of remedies 
and of diseases of the skin increases. 

The medicinal eruptions are at times difficult to make out, 
on account of their close resemblance to other affections of 
the skin. Their history and their rise and subsidence co- 
incident with giving or withholding the drug will usually 
serve in assisting the diagnosis. 

In addition to the above forms of dermatitis, other forms 
sufficiently distinctive to demand mention under an especial 
head will be found below. It must be observed that this sub- 
division of dermatitis is only provisional, and the designation 
must for the present be a sort of Tom Tiddler's ground, where 
diseases which can claim no other home in our nosology may 
find a place. 

Dermatitis Exfoliativa (ii). This is a rare disease, 
characterized by the local or general occurrence of an acute 
erythematous, more rarely vesicular or bullous, inflammation 
of the skin, with more or less marked febrile disturbance, 
accompanied or followed by degrees of desquamation or 
exfoliation of the epidermis, and marked by a tendency to 



DISSECTION WOUND OR TUBERCLE. 63 

relapse. The rash resembles that of scarlatina, and also that 
of pityriasis rubra and eczema universale. (See descriptions 
of the last two diseases.) 

Dermatolysis (iv). Dermatolysis is an exceedingly 
rare anomaly of the skin, consisting in a more or less circum- 
scribed hypertrophy of the cutaneous and subcutaneous 
structures, characterized by softness and looseness of the skin, 
and a tendency to hang in folds. It is a rare and very striking 
affection, and may occur over various parts of the body. 
Sometimes developing to an enormous size. Herr Haag, 
the " Elastic Skin Man," who has been exhibiting himself 
in various parts of the country for the past few years, pre- 
sents a striking instance of an anomaly closely allied to derma- 
tolysis. Here, however, a remarkable looseness and elasticity 
of the connective tissue, is the chief characteristic. The 
treatment of the circumscribed forms of the disease is re- 
moval by the knife, when this is practicable. 

Dermatosyphilis. (See Syphiloderma, or syphilis of the 
skin.) 

Dissection Wound or Tubercle (ii). The results of 
inoculation from dead bodies may be local, confined to the 
point of inoculation, or they may be general, producing 
severe constitutional disturbance. Usually the disease begins 
by the formation of a small vesicle or pustule on a hard, 
inflammatory base, or of a patch of reddish or violaceous 
induration, occurring at some point of inoculation, in an 
abrasion, etc. There is also burning, itching, with pain 
usually extending up the arm to the axilla, and lymphangitis, 
with constitutional symptoms. The wound, as soon as de- 
tected, should be thoroughly washed and sucked, or soaked 
in a solution of chloride of zinc, or burned with this caustic. 

In other cases the disease is strictly local, being circum- 
scribed, indurated and painful. The epidermis becomes 
thick and fissured, the sore secreting a thick or thin fluid, 



64 DISEASES OF THE SKIN. 

resulting in a crust. In other cases the disease begins in a 
papule or tubercle, which may assume a warty character. 
To this the name of verucca necrogenica, or dissection 
tubercle, has been given. Its usual seat is about the fingers 
and joints. The course of the disease is chronic, and it is 
generally rebellious to treatment. Stimulating ointments, as 
the oleate of mercury ointment, 10 to 20 per cent, strength, 
nitrate of silver, caustic potash and acetic acid, are among 
the remedies usually recommended. A surgeon of much 
experience has recently advised that the warty lesions and 
skin around them should be steeped thoroughly in solution 
of the acid nitrate of mercury. This is to be repeated from 
time to time, as its effects pass away. It must be done 
repeatedly, at short intervals. Patience and perseverance 
for some months are required. 

Driving in Eruptions. When, as formerly, skin dis- 
eases were supposed to be due to some " acrid humor in the 
blood," which, in its struggle to escape by the emunctories 
of the skin, dealt destruction of tissues generally in rending 
its way out, physicians avoided most sedulously any attempt 
to "check the rash," for fear that, being prevented from 
escaping by this natural channel, the disease might "fall 
upon" some vital part. Some such view was extensively 
prevalent until quite recent years, and even now I fear that 
this superstition affords an easy way of escape, on the part of 
not too scrupulous physicians, from the treatment of obstinate 
and troublesome skin diseases, especially in children. Cases 
are occasionally cited, in which the "suppression" of an 
eruption has been followed by disease of the brain or lung, 
or by a still worse eruption somewhere else, and it has been 
imagined that the latter was effect and the former cause. 
But no particle of proof, or even of reasoning, has been 
brought forward to prove this notion, which, in fact, is as 
absurd as to imagine the general drying up of wells and 



DYSIDROSIS. 65 

springs observed in the neighborhood of Vesuvius just before 
a volcanic outbreak must be the cause of that "eruption." 
For my part, there are many stubborn skin diseases which I 
should be only too glad to "drive in" or "dry up," either 
in my patients or my own person, were I thus afflicted, and 
I would cheerfully run any risk to be imagined by the advo- 
cates of acrid humors, rather than permit a painful and dis- 
gusting skin affection, as eczema, for instance, to go uncured. 
Dysidrosis (ii). This is a more or less inflammatory 
disease of the skin, characterized by peculiar vesicles and 
blebs and an excoriated state of the skin, with maceration 
and exfoliation of the epidermis. Minute isolated vesicles 
appear deeply under the skin, which do not incline to rup- 
ture, and after a few days increase in size, assume a yellowish 
color, and look like boiled sago grains implanted in the 
skin. Later the vesicles rise above the skin, coalesce and 
form larger blebs, still showing no disposition to break and 
discharge. After some days the fluid is discharged or the 
blebs dry up, and desquamation takes place, leaving an 
abraded surface. There is no inflammation, as a general 
thing. The hands and feet are most apt to be affected, 
although the affection may occur elsewhere. After a time 
the epidermis may become macerated and sodden, and the 
skin is apt to be sore and painful. The disease may affect 
the backs of both hands and the forearms. Dysidrosis re- 
sembles eczema, but the history of its appearance and course, 
as just given, is different. Patients are apt to be nervous, weak 
and depressed. The treatment must be directed against the 
general symptoms, the local treatment being that of eczema, 
of a similar character and appearance. Authorities are much 
divided regarding the nature of the disease. Some think it a 
closure of the sweat ducts, and hence its name. Others think 
it simply a formation of inflammatory bullae, occurring so 
often on the hands as to merit the title Cheiropompholyx. 



66 DISEASES OF THE SKIN. 

Ecthyma (ii). Ecthyma is an inflammatory disease of 
the skin, characterized by the formation of one or more 
discrete, flat pustules, the size of a finger nail, situated upon 
a firm, inflammatory base, followed by an excoriated surface 
and a brownish crust. The pustules, generally well developed, 
may be single or numerous. They are notably flat, broad, 
and seldom fully distended. At first yellowish, they are later 
of a reddish color ; in size they vary from a small to a large 
finger nail. There is usually a hard, red, tender areola. 
The lesions dry into flat crusts, of a dark brownish color, 
which, when raised, show an excoriation covered with a 
sanious excretion. The legs, shoulders and back are the 
seat of the lesions, which come out successively, day after 
day, while the attack lasts, each one lasting five to ten days. 
Sometimes there is a little feverishness before the outbreak 
of the eruption, which itself is accompanied by heat, itch- 
ing, and a certain amount of pain. 

Ecthyma is the outcome of want, misery and alcoholism ; 
it occurs in persons who live in the slums, in prisons and in 
almshouses, and who have been subjected to privation. Im- 
proper and insufficient diet; the abstention from food, as in 
prolonged alcoholic debauch ; want of ventilation ; excessive 
work, and uncleanliness are among the causes of the dis- 
ease. 

Ecthyma may be confounded with eczema pustulosum, im- 
petigo, impetigo contagiosa, impetigo herpetiformis, and the 
large, flat, papular syphiloderm. From eczema it is distin- 
guished by the size, form and discrete arrangement of its 
pustules, by the indurated base and the areola, the large, flat 
pustule, the excoriation, and the brownish or blackish crust. 
The character of the pustule and crust distinguishes it from 
impetigo or impetigo contagiosa. From the latter its non- 
contagious character and different distribution distinguish it. 
The history will distinguish it from impetigo herpetiformis. 



ECZEMA. 67 

From the large, flat, pustular syphiloderm, which ecthyma re- 
sembles closely in some respects, it is chiefly distinguished by 
its base, which is merely excoriated, whereas the removal of the 
crust in the syphilitic lesion shows an ulcer beneath, with pus. 
(See Eczema pusiulosum, Impetigo, Impetigo herpetiformis, and 
Syphiloderma pustu/osum.) 

The internal treatment of ecthyma should be tonic and 
supporting. Good hygiene and diet are requisite. Rest, 
fresh air, bathing, cleanliness, with such nourishing food as 
milk, eggs, strong soups, etc., and in a few cases the moderate 
use of alcoholic and malt liquors, are all of the first import- 
ance. Iron, quinine, strychnia and the mineral acids are of 
especial value. Warm alkaline baths, to soften the crusts, 
when numerous, or cooling lotions, when inflammation is 
present, may be employed. The lesions should be dressed 
with some simple, slightly-stimulating ointment, as this : — 

R. Bismuthi Subnitrat ^j 

Ung. Zinci Oxidi, 

Ung. Petrolii aa giv. M. 

Or, this: — 

R. Hydrarg. Chlor. Mite gr. x 

Ung. Aquae Rosae, 

Ung. Petrolii aa ^iv. M. 

The prognosis is favorable; a few weeks are generally 
enough in which to effect a cure, if the patient can follow out 
the treatment carefully. 

Eczema (ii). Eczema is by far the most common of all 
diseases of the skin encountered in this country. The sta- 
tistics of the American Dermatological Association for the 
past five years show that out of 58,617 cases of skin diseases, 
occurring in all parts of the United States and Canada, no 
fewer than 18,525, or nearly thirty-two per cent., were cases 
of eczema. When we add to this the fact that most cases of 
eczema are either disfiguring to the personal appearance or 



bO DISEASES OF THE SKIN. 

are accompanied by more or less burning, itching or other 
uncomfortable and painful sensations, it must be admitted 
that this disease is the most important of all for the physician 
to know and to treat intelligently. 

Eczema is an inflammatory acute, or chronic, non-contagious 
disease of the skin, characterized at its commencement by 
erythema, papules, vesicles or pustules, or a combination of 
these lesions, accompanied by more or less infiltration and 
itching, terminating either in discharge, with the formation 
of crusts, or in desquamation. It is eminently a protean dis- 
ease. At one time it begins as an erythema ; later this may 
become moist and secreting, and finally terminate in a thick- 
ened, dry and desquamative surface. At another time the 
affection may begin in the form of vesicles or pustules, with 
swelling and heat. These soon burst, and a red, weeping 
surface results, which is soon coated with bulky crusts from 
the drying of the liquid, gummy discharge. The character 
of the patch may then suddenly change, and instead of a 
weeping surface there may exist a dry, scaly, infiltrated, 
fissured piece of skin, which continues until the disease is 
removed. Or, again, papules may first appear; these may 
remain as such throughout their course, or may pass into 
other lesions, or they may be associated sooner or later with 
vesicles. 

There is no other disease of the skin in which the lesions 
undergo such sudden and manifold changes, and every variety 
may manifest itself in turn upon the same individual. 

More or less itching is almost always present in eczema. 
It may vary in degree from the merest titillation to un- 
endurable torture. Sometimes burning takes the place of 
itching ; at other times they occur together. But eczema is 
the itching disease, par excellence. 

Eczema may be acute, running its course in a few weeks 
and then permanently disappearing, or it may be chronic 



ECZEMA. 69 

and continuous, or recurring through years. It may occur 
in small patches single or multiple, or more rarely covering 
extensive surfaces. Unless very extensive it is not ushered 
in by constitutional symptoms. 

The varieties of eczema are named according to the lesions 
which the disease assumes at its beginning. These are as 
follows : — 

Ecze7?ia erythematosum. This form shows itself in typical 
cases, first as an undefined erythematous state of the skin, 
occurring in small or large patches without discharge or 
moisture. Commonly the patch, which is sometimes slightly 
infiltrated, is covered with fine, thin scales of epidermis, and 
now and then the surface is slightly excoriated. The skin 
may be bright or dark red, or even violet. It often has a 
yellowish tinge. It is occasionally mottled. The process 
may affect a small surface or a large one ; it is often better 
one day and worse the next, as it may even go away entirely 
only to return a little later. It is apt to be chronic, and the 
relapses are annoying and discouraging, especially in winter 
time. The influence of exposure to external heat or cold, 
a heavy meal or indulgence in alcoholic drink, is apt to be 
followed by an exacerbation of the disease. Burning and 
itching, alone or together, are prominent symptoms. Eczema 
erythematosum may run its course as such, or may develop 
into Eczema squamosum. Vesicles or pustules are rarely 
seen. Eczema erythematosum is most apt to occur upon 
the face and genitals. 

Eczema vesiculosum. Vesicular eczema commonly begins 
by a feeling of heat and irritation in the part, which shows a 
diffused or punctate redness, with itching and burning, and 
small vesicles soon show themselves, either alone or grouped, 
or sometimes running together. They are soon filled with a 
yellowish, gummy fluid, and then they ordinarily break and 
form a crust. Sometimes, however, the vesicles simply dry 



70 DISEASES OF THE SKIN. 

up without breaking. In more marked cases new crops of 
vesicles continue to come out, and when a considerable 
surface is covered, the quantity of fluid poured out is quite 
large, and the underclothing or dressings are saturated. 
When the secretion dries, it is very sticky and tenacious, and 
this is characteristic of this form of eczema. Typical eczema, 
as described, is not as common as the more complex varieties 
when the lesions are multiform; papules, papulo-vesicles, 
vesicles, pustules and other lesions being found in conjunction. 
The two chief characteristics of this form of eczema, wher- 
ever found, are the itching and the gummy secretion, leaving 
a yellow stain upon the linen. Patients are almost always 
struck by this feature. 

Vesicular eczema may occur in very small patches, or in 
quite extensive areas. As it shows itself in children over 
the face and scalp, it forms the eruption popularly known as 
milk crust, scald head, tooth rash or moist tetter. 

Eczema pustulosum {Eczema impetiginosum). Pustular 
eczema is very much the same in its original appearance as 
vesicular eczema, only that the lesions assume the form of 
pustules rather than of vesicles. There is usually less heat 
and itching. A strict line cannot be drawn between the 
two forms, for they are apt to run into each other, and may 
coexist on the same subject and in the same patch. The 
scalp and face are favorite seats of pustular eczema, and it is 
apt to occur in children who are badly nourished or who are 
being brought up by hand. It also occurs in ill-fed and 
scrofulous adults. The same causes which would bring on 
vesicular eczema in a tolerably healthy individual will arouse 
the pustular form in a poorly nourished person. For this reason 
pustular eczema always calls for tonic and supporting treatment. 

Eczema papillosum. Papular eczema appears in the form 
of small, round or acuminated papules, varying in size from 
a small to a large pin's head. In color the lesions are bright 



ECZEMA. 71 

or dusky red, sometimes violaceous. They may be discrete, 
or may run together, forming large patches, and these are 
often infiltrated. Now and then they become abraded and 
moist, forming eczema rubrum. Papular eczema is apt to 
occur on the arms, trunk and thighs, especially the flexor sur- 
faces. It may involve a very small surface, or it may cover 
a large area of the body, and it is apt to be the most stubborn, 
troublesome and annoying of all the forms of eczema. Itch- 
ing is the most prominent and troublesome symptom; at times 
this is agonizing. Patients tear and gash themselves, in their 
efforts to gain relief, and I have seen chronic cases where the 
nails have been worn to the quick and the ends of the fingers 
polished by the almost ceaseless efforts of the patient to assuage 
the torment, if only for a moment. 

Eczema rubrum. This must be regarded rather as a second- 
ary condition resulting from previous morbid action, than a 
distinct variety. It is a variety only in a clinical sense. It 
may result from eczema erythematosum, vesiculosum, pustulo- 
sum or papulosum. In eczema rubrum the surface of the 
skin is inflamed and infiltrated, red, moist and weeping ; oc- 
casionally it is more or less covered with yellowish or brownish 
crusts, often completely overspreading the part. Unless 
artificially detached, these crusts may sometimes continue to 
adhere, the process of exudation meanwhile going on under- 
neath. Under these circumstances the appearance of a rough, 
dirty, yellowish or brownish scale is observed, instead of the 
shining, red, oozing surface. Eczema rubrum may occur upon 
any part of the body, although it is most commonly found 
upon the legs or the flexures of the joints, particularly the 
former. The swollen, infiltrated, violaceous, red leg of ec- 
zema rubrum, with its varicose veins, its glazed and shining, 
or raw surface oozing serum at a thousand pin-head orifices, 
and furiously itching and burning, is a characteristic spectacle 
not to be forgotten when once seen. 



72 DISEASES OF THE SKIN. 

Eczema squamosum. Scaly eczema is an important clinical 
variety of the disease. Like E. rubrum, it follows and results 
from the erythematous, vesicular, pustular or papular forms of 
the disease. It is particularly apt to succeed erythematous 
eczema. When typical, it shows itself in the form of variously 
sized and shaped reddish patches, which are dry and more or 
less scaly. The skin is always more or less infiltrated or 
thickened. Squamous eczema may be only an ephemeral 
stage in the evolution of the disease. More commonly, 
however, the term is applied to denote a chronic condition, 
which may last for a long time. 

Other lesions are encountered in eczema which are worthy 
of mention. These are rhagades or fissures, occurring when 
the diseased and infiltrated skin becomes cracked by flexure, 
as about the joints or at the margins of the lips or anus. 
Chapped hands, for example, are typical instances of fissured 
eczema. Sometimes eczema may assume a warty condition, 
and at other times hard, sclerosed patches may form. 

In addition to the clinical varieties of eczema above 
described, the disease may fitly be divided into varieties, 
according as it assumes the acute or chronic form. The divi- 
sion, which is a distinct one, refers not so much to the actual 
duration of the disease, as to the pathological changes which 
occur during its course. When the general inflammatory 
symptoms are high and the secondary changes insignificant, 
the disease may be said to be acute. When, however, the 
process has settled into a definite course, the same lesions 
continually repeating themselves, accompanied by secondary 
changes, the disease is to be considered chronic. 

Eczema is, as I have said, by far the commonest of all skin 
diseases. It attacks persons in all grades of society, and 
occurs at all ages and in both sexes. In some cases it appears 
to be, in a certain sense, hereditary. I have found it com- 
monly in the children of persons of light complexion, with 



ECZEMA. 73 

fair to reddish hair, with a tendency to scrofulous affections. 
Some persons are so prone to eczema that the slightest provo- 
cation will bring on the eruption, and an attack of dyspepsia, 
which in another person would have no effect on the skin, 
or contact with an irritant which in most persons would only 
cause a transient dermatitis, are, in such individuals, a suffi- 
cient cause to bring out an eczematous eruption. Dyspepsia 
and constipation are among the commonest constitutional 
causes of eczema. In certain individuals the presence of an 
excess of uric acid and urates in the system is sufficient to 
produce and keep up eczema. The occurrence of gout and 
rheumatism in connection with eczema has often been alluded 
to by writers. I am inclined to think, however, that gout 
is among the rarer exciting causes. It is certain, indeed, 
that this disease is rare among the younger generation in 
Philadelphia ; and I may say, so far as my personal expe- 
rience goes, that, in between three and four thousand cases 
of eczema which I have treated, not more than two or three 
have occurred in connection with the gouty diathesis. Im- 
proper food, as to quantity and quality, acts as an exciting 
cause. During a period of commercial depression which 
occurred some ten years ago, I found many working people 
the subjects of eczema, clearly brought on or much aggra- 
vated by coarse and insufficient food. It is, however, among 
infants and young children that this cause of eczema most 
frequently comes into play. Pregnancy and lactation, debility, 
nervous exhaustion, excessive mental or bodily work, denti- 
tion, vaccination, internal irritation, as of ascarides or taenia 
in the bowels, may also determine the eruption of eczema. 

Eczema is not contagious. It cannot be acquired from 
being in contact with or handling the discharge. 

Among the local causes of eczema, which are numerous 
and important, and which give rise to the condition known 
as "artificial eczema," are certain cutaneous irritants, as 
6 



74 DISEASES OF THE SKIN. 

croton oil, mercurial ointment, tincture of arnica, tincture 
of cantharides, mustard, antimonial ointment, sulphur and 
turpentine. Here also may be mentioned the rhus venenata 
and toxicodendron, the poison oak and ivy. All these irri- 
tants, and especially the latter, usually provoke dermatitis 
(see Dermatitis venenata), yet may, in certain individuals 
and under certain circumstances, give rise to true eczema. 
Heat and cold, excessive perspiration, especially about the 
genitalia, and other places where the skin inclines to form 
folds, may give rise to the affection, which under the latter 
circumstance is known as eczema intertrigo. 

Eczema is of much commoner occurrence in the winter 
than in the summer. The atmosphere of January and Febru- 
ary, and particularly the cold bleak weather of March, seem 
to favor the occurrence of the disease. 

Many cases of eczema get well in summer only to recur 
again in winter. Water, as in water dressings or in fomenta- 
tions, or in the inordinate use of bathing, may be a cause of 
eczema. The insensate declamation against filth, or want of 
personal cleanliness, as an almost universal cause of skin 
diseases, which is too common, not only among superficial 
writers, but among physicians who ought to know better, 
would in many cases be better replaced by a caution against 
excessive ablution. The custom of very frequent bathing, 
especially when soap is used, is often harmful to the skin to 
a considerable degree. Alkalies, acids, strong and harsh 
soaps, may give rise to chapping and Assuring of the skin 
and to eczema. Some years ago, when sapo viridis was first 
introduced, and when the view that it was in some way a 
specific against skin diseases was prevalent, I frequently saw 
severe and extensive eruptions of eczema, which had been 
brought about by the injudicious and improper employment 
of this semi-caustic application. Finally, among the local 
causes of eczema, may be mentioned the irritation caused 



ECZEMA. 75 

by the presence of lice and itch mites, together with the 
scratching to which they give rise. 

The diagnosis of eczema is of great importance, especially 
as the disease shows itself in such protean forms. There are, 
however, certain features of eczema, one or more of which 
are present in every form of the affection, and these may 
serve to aid in the diagnosis. Inflammation of the skin 
exists in a greater or less degree in all cases of eczema. It 
is indicated by a certain thickening of the skin, which may 
usually be seen by the eye, and in most places detected by 
rolling a small pinched-up portion of the skin between the 
finger and thumb. Swelling and cedema exist in all acute 
eczemas, and often in chronic cases. The patch is red and 
congested. In most cases of eczema there has been more 
or less fluid exudation or moisture, at one stage or another, 
in the history of the disease. This is termed weeping, dis- 
charging or running. The fluid may be clear, limpid and 
yellowish, turbid and puriform, or it may contain blood. 
This discharge is a most characteristic feature of eczema, 
and is not present in any other disease. The crusts formed 
by the drying up of the discharge are characteristic. When 
this has been copious the crusts form rapidly, and in quantity 
so as sometimes to cover and mask the skin. They are yel- 
lowish, brownish or greenish in color, and when removed 
show a moist surface beneath. Among the most important 
diagnostic symptoms of eczema is the subjective one of itch- 
ing. It is often intense, being more marked than in other 
diseases. It is never altogether absent, though it may vary 
much in degree. Burning is also a not unfrequent subjective 
symptom, being more apt to be present in erythematous 
eczema, and often giving way to itching as the disease pro- 
gresses. The itching of eczema often gives rise to an irre- 
sistible inclination to scratch, as was noted in speaking of 
the papular variety of the affection. 



76 DISEASES OF THE SKIN. 

The diseases with which eczema is most likely to be con- 
founded are the following: — 

Erysipelas sometimes resembles eczema erythematosum, 
especially as it occurs upon the face. It is, however, acute ; 
it begins at a given point and creeps slowly from place to 
place. The inflammation is a deep one ; the surface is 
smooth, shining, tense and more or less dusky red, while 
deep infiltration, cedema, heat and swelling exist underneath. 
Erysipelas is also accompanied by considerable fever and 
constitutional disturbance. There is no discharge from 
erysipelas save that from bursting bullae, which sometimes 
form during the latter stages of the disease. 

Urticaria, particularly that variety accompanied by the 
formation of small, papular lesions, is occasionally mistaken 
for eczema papulosum. The irritable condition of the skin, 
the history of itching and burning occurring before the 
appearance of the lesions, all characterize urticaria in contra- 
distinction from eczema. 

Herpes zoster sometimes resembles eczema vesiculosum, but 
is distinguished from it by the arrangement of the vesicles, 
the more regular grouping of the lesions of zoster along the 
line of some well-known nerve trunk, and the ordinary re- 
currence of neuralgia in connection with the zoster eruption. 

Pityriasis, as it occurs upon the scalp, is often very difficult 
to distinguish from eczema squamosum occurring in the same 
locality. The difficulty of diagnosis is occasionally enhanced 
by the simultaneous occurrence of both affections upon the 
same individual. In eczema, however, the scales are larger, 
less abundant and dryer than in pityriasis. Eczema is more 
apt to occur in a patch on the scalp, while pityriasis is more 
generally diffused. The skin in eczema is usually red and 
inflamed, and is always itchy; in pityriasis it may be even 
paler than normal, and may have a dull, leaden hue. It is 
commonly less itchy, also. 



ECZEMA. 77 

Psoriasis is often confounded with eczema, the disease, 
when occurring in limited patches or upon the scalp, being 
sometimes almost indistinguishable. Old, infiltrated, in- 
flammatory patches are especially difficult to make out, but in 
psoriasis the edges usually terminate abruptly, while in eczema 
they are more apt to fade into the surrounding skin. The 
scales on eczema patches are thin and scanty ; on the patches 
of psoriasis they are comparatively more abundant, larger, 
silvery and imbricated. In eczema there is usually some his- 
tory of moisture or weeping, in one stage of the disease or 
another ; in psoriasis the process is always dry. The distri- 
bution of the disease, and the occurrence of patches on other 
parts of the body, may aid in the diagnosis. In doubtful 
cases, where only a few scattered lesions are presented for 
examination, the whole surface should be diligently searched 
over, for a single lesion in some part of the body may, by its 
typical aspect, betray the nature of the disease where the ma- 
jority of the lesions are quite doubtful in appearance. 

Lichen ruber may be confounded with eczema, but the 
peculiar shape of the lesions in lichen ruber planus, to be 
described further on, together with their dusky hue, and the 
fact that they usually run a quiet, chronic course, without 
change, and leave a deep stain behind, all seem to distinguish 
this affection from eczema. 

Pityriasis rubi-a is a very rare disease, and is so seldom met 
with in this country (but two authentic cases, I believe, being 
on record), that it is not likely to be encountered. It pre- 
sents symptoms, however, which resemble closely those of 
generalized erythematous and squamous eczema. It may be 
distinguished, however, by its universal redness ; great masses 
of large, thin, papery, whitish, epidermic scales, which con- 
tinually reproduce themselves; slight itching; burning heat; 
and, lastly, by the absence of marked infiltration, and thick- 
ening of the skin, a symptom common in eczema. It under- 
goes but slight changes throughout its course. 



78 DISEASES OF THE SKIN. 

Tinea circinata is sometimes mistaken for eczema, but the 
course of the two diseases is quite different, and the micro- 
scope will almost invariably settle the question of diagnosis 
by showing the presence or absence of the characteristic 
fungus of tinea. Tinea tonsurans, in its milder and more 
chronic stages, may readily be mistaken for eczema ; the 
diagnostic points will appear in the description to be given of 
that affection later on. 

Sycosis, both of the parasitic and non-parasitic varieties, 
sometimes resembles eczema of the beard. The former, how- 
ever, is scantily crusted, and when the crusts are removed, 
instead of the smooth, soft surface of eczema, a rough, dusky- 
red, mamillated surface is revealed. The loose hairs are also 
loaded with the characteristic microscopic fungus about their 
roots. Sycosis non-parasitica is essentially an inflammation 
of the hair follicles, and while eczema is superficial, sycosis 
leaves the surface alone and attacks the follicles only. 

Favus, a disease of rather rare occurrence in this country, 
sometimes resembles eczema ; but the peculiar canary-yellow 
color of the favus crusts is almost unmistakable, and the 
microscope will quickly settle the question of diagnosis, for 
the peculiar fungus of favus is very abundant in the lesions of 
this disease. 

Scabies is very likely to be confounded with eczema, and the 
diagnosis is often difficult. This can easily be understood 
when it is considered that the eruption of scabies is, in fact, 
largely an eczema. Eczema, however, does not show the 
marked preference for certain localities, as the hands and 
fingers, buttocks, axillae, abdomen, mammae, nipples and penis, 
which scabies displays. But, chiefly, the presence or absence 
of the peculiar burrow of the itch insect will decide almost 
infallibly between the two affections, and the success or non- 
success of the anti-parasitic treatment will settle the question. 

Syphilis. Eczema of the scalp is at times liable to be 
mistaken for syphilis. There is a form of pustular eczema, 



ECZEMA. 



79 



characterized by the presence of a few scattered lesions of 
the scalp, without a sign of disease elsewhere, which it is 
sometimes difficult to differentiate from the pustular syphilo- 
derm of the scalp. The occurrence or absence of a history 
of syphilis, or of concomitant syphilitic lesions in other parts 
of the body, and the success or failure of a treatment other 
than anti-syphilitic, will demonstrate whether one or the other 
affection is present. Occasionally fissures with abundant 
purulent secretion occur on the scalp in the course of syphilis, 
and this form of the eruption may closely resemble confluent 
pustular eczema. I met with such a case some years ago, 
where the diagnosis was extremely difficult, and where the 
ordinary anti-syphilitic remedies even failed for a time to 
give relief. The disgusting odor which ordinarily accom- 
panies the discharge from this form of syphilitic disease, will 
usually, however, serve to distinguish it. 

In a work like the present it is obviously impossible to do 
more than indicate, in a general way, the plans of treatment 
suitable for the various forms of eczema. The reader is 
referred to the larger works on skin diseases, and especially 
to the various monographs, as those of McCall Anderson 
and Bulkley, which deal with the subject in a more com- 
prehensive manner. 

Eczema is a perfectly curable disease, but for its relief 
both internal and external remedies must at times be em- 
ployed. Constitutional remedies judiciously employed are 
almost always needful, and prove of decided benefit in the 
majority of cases. In some cases, as where the eruption is 
local and due to some external irritant, or where it is ex- 
ceedingly limited in extent, no internal measures are called 
for. The subject of diet must be carefully attended to ; all 
articles which are difficult of digestion must be avoided, and 
especially salt or pickled meats, pastry, cabbage, cheese and 
beer, or wine.* The bowels should be carefully regulated ; 
*See Appendix, on Diet in Diseases of the Skin. 



80 DISEASES OF THE SKIN. 

dyspepsia is often the sole exciting cause of eczema, and the 
physician who desires to treat this affection in any of its 
forms with success, should be prepared to deal with dyspepsia 
in the majority of cases. The condition of the kidneys 
should be looked into. Diuretics are frequently of value. 
Saline laxatives are frequently called for in the treatment of 
eczema, and among these the following tonic aperient, to 
which the name of " Mistura ferri acida" has been given, 
is one of the best : — 

R. Magnesii Sulphatis ^j 

Ferri Sulphatis gr. iv 

Sodii Chloridi sjss 

Acidi Sulphurioi dil f^ij 

Infus. Quassise ad f|jiv. M. 

Sic — A tablespoonful in a tumbler of water, before breakfast. 

This preparation, though extremely disagreeable on first 
taking, becomes much less revolting after using for a short 
time, and even delicate women can take it readily. It is 
important that the full quantity of water should be taken, 
as the volume of fluid seems to influence the action of the 
medicine. Sometimes hot water is less unpalatable with this 
mixture than lukewarm or cold water. In some cases, espe- 
cially in winter time, the proportion of magnesium sulphate 
must be increased. The laxative mineral spring waters, as 
the Hathorn and Geyser springs of Saratoga, or the Fried- 
richshall, Hunjadi Janos and Ofener Racoczy, among German 
mineral waters, the latter mentioned in the order of their 
increasing purgative properties, are beneficial in many cases. 
I like the Hunjadi Janos best for most cases, and I sometimes 
prescribe it after a short course of the mistura ferri acida, 
as its use can be kept up indefinitely without an increase of 
dose. In infantile eczema, where constipation exists, the 
simple unspiced syrup of rhubarb, in repeated small doses 
alone or with magnesia, is often found desirable. A very 



ECZEMA. 81 

good powder (though powders are disagreeable prescriptions 
for children, I know not what to substitute for this), is the 
following : — 

R. Hydrarg. Chlor. Mite gr. xij 

Pulv. Rhei gr. xviij 

Magnesii Calcinat 3 ss. M. 

Div. in Chartae No. vj. 

Sig. — One, at night. 

This is for an infant six months to a year old, of average 
strength. In weakly infants the dose of calomel and rhubarb 
should be slightly reduced. The powder should be con- 
tinued until its effect is seen. Purgation, however, should 
not be induced. A somewhat similar prescription, in a fluid 
form, is the following : — 

R. Pulv. Rhei., 

Sodii Bicarb aa .^i-iij 

Aquae Menth. Pip f^ iv - M - 

Sig. — A teaspoonful, after meals. 

In adults, especially when the eczema is acute, and occurs 
in a robust, sthenic individual, the laxative treatment is best 
introduced by a brisk mercurial purgative. Especially is 
this the case when the patient is suffering from constipation 
when first seen. Here the bowels are to be thoroughly un- 
loaded, to begin with, and then we may enter upon the more 
direct treatment of the disease. It is wonderful to see what 
a good effect two or three compound cathartic pills, or six 
grains of blue mass, given the evening before beginning the 
administration of mistura ferri acida, will have on the patient's 
comfort, external and internal. Some good authorities, I 
know, deprecate the employment of cathartics in the treat- 
ment of eczema, but the general experience is in favor of 
thus beginning the treatment, — in acute inflammatory eczema, 
be it understood, and this is certainly my advice. Afterward 
let the case be treated internally, on general medical prin- 



82 DISEASES OF THE SKIN. 

ciples, and let cathartics and laxatives be given or withheld, 
as the patient's condition suggests. In old persons, particu- 
larly when the patient has been a high liver or is rheumatic, 
or in those unusual cases where a gouty element may exist, 
diuretics and alkalies are indicated. In such conditions the 
following prescription was recommended by the late Tillbury 
Fox: — 

R. Magnesii Sulphat giv 

Magnesii Carbonat gj 

Tinct. Colchici TT^xxxvj 

01. Menth. Pip mjj 

Aquae f ^ vij . M. 

SlG. — Two tablespoonfuls in a wineglass of water, every three or four 
hours. 

The acetate and carbonate of potassium in full doses, and 
also the alkaline mineral waters, may be employed. In per- 
sons of debilitated constitution or in scrofulous persons, 
particularly in the badly-nourished children of tuberculous 
parents, cod-liver oil is demanded, and is frequently very 
useful. Iron in various forms is to be recommended in some 
cases. The following prescription is one which I often em- 
ploy with satisfaction : — 

R . Tinct. Ferri Chlor. 

Acidi Phosphorici dil...aa... f^j 

Syrupi Limonis ad... f^iv. M. 

SlG. — A teaspoonful in a wineglass of water, after meals. 

Syrup of the iodide of iron and wine of iron are also eligible 
preparations, particularly for children. Quinine and strychnia 
are sometimes called for by the general condition of the 
patient. Arsenic is useful in a limited class of cases, more 
especially in the chronic papular form and the squamous 
stage of the affection. In former times the use of arsenic in 
eczema of all grades and varieties was much abused, and even 
now it too often forms a part of that routine treatment which 



ECZEMA. 83 

is the refuge of ignorance. Frequently, so far from doing 
good, it does harm by upsetting the stomach, and its use is 
particularly pernicious in the acute and inflammatory forms 
of the disease. An admirable resu?ne of the value and indi- 
cations for the employment of arsenic in skin diseases in 
general is given by Duhring in his treatise. Tar has been 
used in some chronic cases internally, with benefit. Sulphur- 
spring waters are also said to be useful occasionally. I have 
no personal experience with regard to these latter remedies. 

Regarding the local treatment of eczema, ordinary water 
may be employed for washing purposes, in most cases ; when 
the skin is delicate and sensitive, distilled water or water 
made milky by the addition of some bran or starch. A very 
good method of softening the water, particularly where it is 
to be applied to the face, is to take a handful of bran, sew it 
up in a small linen bag, and squeeze the bag, like a sponge, 
through a basin of water until the water is quite milky. This 
gives a soft and agreeable quality to the water when it is ap- 
plied to the skin. The water may be used cold or warm, as 
best suits the feelings or fancy of the patient; but the most 
important point is not to use too much of it or too often. 
The best rule for the use of water in eczema is to use it as 
seldom and as sparingly as possible. The only two indica- 
tions for its employment are either the removal of crusts or 
the cleansing from absolute and unendurable assoilment; 
water sometimes seems to act upon the eczematous skin almost 
like poison. White castile soap is ordinarily the only soap 
necessary to cleanse the skin of crusts and scales, but occa- 
sionally the stronger potash soaps, the ordinary household 
soft soap, or the "sapo viftdis" of Hebra, must be brought 
into use. Sometimes the "spiritus saponis kalinus," or solu- 
tion of two parts of sapo viridis in one part of alcohol, may 
be used instead of the solid soaps. Whatever soap is em- 
ployed, it should always subsequently be completely washed 



84 DISEASES OF THE SKIN. 

off the skin, unless a distinctly macerating or caustic effect is 
desired. 

The local treatment of eczema is of great importance ; 
many cases can be cured by outward applications alone, and 
there are very few where these can be dispensed with entirely. 
Before instituting local treatment, the part affected should be 
examined, with the view of determining whether the disease 
is acute or chronic, and what the characteristic lesions, the 
amount of heat, redness, swelling, etc. ; and also the con- 
dition of the epidermis, whether intact or torn and abraded. 
It is most important, also, to ascertain the area involved, 
whether this be great or small, for not only must we be on 
our guard not to use irritant remedies, but it must be re- 
membered also that some applications are poisonous by ab- 
sorption, when applied over large raw surfaces. 

In most cases of eczema there are certain secondary pro- 
ducts, crusts, scales and extraneous matter, which must be 
removed before the local remedies can be advantageously 
applied. Sometimes it is difficult to get patients to remove 
these extraneous matters; a feeble attempt is made, giving 
rise, perhaps, to pain or slight bleeding, and the statement is 
offered that the "scab" cannot be gotten off. The mass of 
rancid grease, decomposing pus, serum and sebaceous matters, 
mingled with epithelial debris, make a very poor covering, 
however, for an abrasion or ulcer which is to be healed, or 
to which local treatment is to be applied successfully. The 
physician should give the most precise directions as to the 
method of removing the crusts or, better, should, when practi- 
cable, remove them himself. Soap and water alone will not 
do this. Poultices made with hot almond oil, applied to the 
crusts after these have been themselves thoroughly saturated 
with the oil, will often suffice. At other times, compresses 
wrung out of hot water and covered with oiled silk will do 
better. Frequently a strong solution of carbonate of sodium, 



ECZEMA. 85 

also applied on compresses, will soften crusts more rapidly 
than anything else. Sapo viridis spread on linen rags, like 
ointment, laid on the skin and covered with waxed paper or 
oiled silk, will soften the most stubborn crusts. Crusts in the 
scalp sometimes cling stubbornly, on account of the numerous 
hairs running through them. By lifting the edge gradually, 
and cutting away the hairs from underneath, the crust can be 
lifted expeditiously and without pain. I dwell on this little 
point because I have so often seen well directed treatment 
fail of its intention, because the way had not been prepared 
for the local remedies. 

Two general principles may be mentioned with regard to 
the local treatment of eczema. These are, first, that in the 
acute form the treatment can scarcely be too soothing; 
secondly, that in the chronic form the treatment can hardly 
be too stimulating. Of course, these general principles must 
be modified somewhat, according to individual circumstances, 
especially with regard to the latter. 

Acute eczema. When a remedy is to be applied for the 
first time to a case of acute eczema, it is usually better to use 
it over a limited area until its effect is perceived, for it must 
be borne in mind that a remedy which has been of service in 
one case will not necessarily suit another, even when the 
general features of the disease are the same. If one remedy 
does not suit, another must be tried, for it is often difficult 
to decide beforehand what application will be most useful. 
The indication is to give ease to the patient, and medi- 
caments must be changed, if necessary, until this end is 
attained. 

In acute vesicular or erythematous eczema, water is, as a 
rule, injurious, and irritates the skin. It should never be 
used, except in cases of extreme necessity, for the absolute 
needs of cleanliness. Patients, especially those belonging to 
the _more refined classes, will sometimes rebel when, for 



86 DISEASES OF THE SKIN. 

instance, they are desired to abstain from washing the face; 
but occasionally uncleanliness, or what passes for such, must 
be enforced. In the place of washing, the face or other 
parts may be powdered, from time to time, with a dusting 
powder, such as the following: — 

R. Pulvis Camphorae ^ss 

Pulvis Zinci Oxidi 3 1SS 

Pulvis Amyli £vj. M. 

The following plan of treating acute vesicular eczema is 
that of Dr. James C. White, of Boston, which I learned from 
Dr. Duhring, and have used in hundreds of cases with great 
satisfaction. I consider it perhaps the best treatment for the 
majority of cases. The affected part is to be bathed with 
lotio nigra, the black wash of everyday use, either in full 
strength or else diluted with an equal part of lime water, and 
daubed over the surface by means of a rag or mop (not a 
sponge, as this absorbs the sediment), or applied by means 
of cloths saturated with the wash and allowed to remain 
on the surface. As a substitute for the ordinary wash, the 
following, nearly the same in character, may be used, espe- 
cially on the face, as it clings better to the skin : — 

R. Hydrarg Chlor. Mite gr. lxxx 

Mucilago Tragacanthse ^j 

Liquoris Calcis ad £ viij. M. 

After the wash has been applied for some minutes, oxide of 
zinc ointment, or in winter the following — 

R. Pulv. Zinci Oxidi gr. lxxx 

Ung. Aquae Rosas, 

Ung. Petrolii aa giv. M. 

is applied gently with the finger, before the surface has had 
time to dry ; and this treatment is repeated at intervals of a 
few hours. As a rule, the itching and burning is relieved at 
once, and occasionally the disease is arrested in its course. 



ECZEMA. 87 

Sometimes the wash may be applied every half hour or hour, 
the ointment being laid on at longer intervals. I have often 
found the following lotion useful; it is to be applied on 
cloths : — 

R. Liq. Plumbi Subacetat dil Oss 

Glycerinae... f% ss. M. 

When there is a good deal of inflammatory action, and 
when the skin is thickened and more or less doughy and 
cedematous, I am in the habit of employing bread poultices, 
made of bread crumb mixed with ice-cold lead water. The 
sedative effect of this application is sometimes extremely 
soothing and grateful. The following lotion is highly recom- 
mended in some cases : — 

R. Pulv. Calaminis ^j 

Pulv. Zinci Oxidi ^ss 

Glycerini gij 

Aquge f^ vj. M. 

It should be applied frequently, by means of a bit of rag 
or a rag mop, the sediment being allowed to remain on the 
surface. I think it would be better to substitute precipitated 
carbonate of zinc for the calamine, as this is usually a gritty 
powder, of a spurious character, being really carbonate of 
baryta. 

Another very good remedy, in my experience, and one 
particularly adapted to the treatment of eczema covering a 
considerable surface, is the following : — 

R. Ext. Grindelise Robustse fid.... fgij 

Aquse Oj. M. 

This is preferably applied on cloths, which are permitted 
to remain in contact with the surface until nearly or quite 
dry, before removal. A lotion of sulphate of zinc, fifteen to 
thirty grains to the pint of water, acts admirably in some 
cases, especially if eczema about the hands. When itching 
is a severe and prominent symptom, applications of hot 



88 DISEASES OF THE SKIN. 

water, or of cloths wrung out of the same and applied in quick 
succession, as hot as may be borne, to the affected skin, often 
allay this exasperating symptom when all else has failed. 
Carbolic acid, which is one of the most efficient anti-pruritics, 
can rarely be employed in the acute stages of eczema, but 
now and then, when burning is less prominent as a symptom, 
and when itching is most tormenting, it is of use. I often 
combine it with black wash, as thus : — 

R. Acidi Carbolici ^ij 

Glycerinse f^ j 

Lotio Nigrse Oj. M. 

I find that the erythematous form of eczema, when the 
skin is yet unbroken, and when there is at the same time 
more or less inflammatory infiltration, is that in which car- 
bolic acid is likely to agree. It must be applied with caution, 
however, in the acute stage of eczema, until it is found to 
agree with the individual case under treatment. 

While, as a general thing, ointments are not found to agree 
in acute eczema, yet in a certain number of cases these 
preparations appear to suit better than lotions. The oxide 
of zinc ointment, that hard ridden and universal remedy for 
skin diseases, here finds its legitimate sphere. Bulkley re- 
commends that instead of being made with lard it should be 
made with cold cream, and should contain sixty instead of 
eighty grains of the oxide of zinc to the ounce. Both of 
these changes are, I think, improvements. Practically, I 
find the oxide of zinc ointment, as dispensed, too thick and 
almost tough, especially for winter use in this climate. So, 
for convenience sake, I ordinarily prescribe it mixed with 
an equal weight of vaseline or cosmoline. It should not 
be benzoated, or if benzoin is used it should be used in small 
quantity. The unguentum aquae rosae is a much better base 
for all or almost all ointments than lard or vaseline. The 
first is apt to turn rancid, while the second is too thin for 



ECZEMA. 89 

ordinary use, although preferable on this very account for 

use in the hairy parts. 

Oleate of zinc, originally brought into notice by Crocker, 

of London, in 1878, enters into the composition of a number 

of ointments which are of frequent value in the treatment of 

acute eczema. It is made as follows : Take one part of oxide 

of zinc, and eight parts of oleic acid ; stir together ; allow 

to stand two hours; heat until dissolved. On cooling, a 

yellowish-white, hard mass results, which may be variously 

made into ointments. The following is one formula: — 
» 

R. Zinci Oleat., 

Olei Olivae aa giv. M. 

Or it may be made up with cold cream : — 

R • Zinci Oleat., 

Ung. Aquae Rosae aa ,^iv 

Olei Amygdalae q. s. M. 

Oleate of bismuth acts in very much the same manner. 
The following formula, brought into notice by Dr. McCall 
Anderson, is an elegant preparation when prepared with due 
pharmaceutical skill : — 

R. Bismuthi Oxidi 5jj 

Acidi Oleici ^j 

Cerse Albae ^iij 

Vaselini sjix 

01. Rosae nyj. M. 

Subnitrate of bismuth is a very agreeable and slightly 
astringent as well as sedative remedy, when used in the form 
of ointment. 

The following — 

R. Pulv. Bismuth Subnitrat 3 ss- 3ij 

Ung. Aquae Rosae Sjj. M. 

is an excellent application in acute eczema of the scalp, par- 
ticularly in children. 

7 



90 DISEASES OF THE SKIN. 

Diachylon ointment, made according to the formula of 
Hebra, with due care, and by a skilled pharmaceutist, is of 
all ointments the most grateful and soothing to the inflamed 
skin. I have, however, so frequently met with disaster in 
having this ointment made up by chance apothecaries, or at 
long intervals, that I have almost given up its use. I give the 
method of its preparation here, so that any one who may be 
fortunate enough to be able to depend upon first-class and 
conscientious pharmaceutical skill may have recourse to this 
prince of ointments. It is composed as follows : — - 

R. Olei Olivae Opt fg xv 

Pulv. Lithargyri ^iij-gvj 

Aquae q. s. 

Coque. Fiat unguent.* 

Diachylon ointment is usually more effective when spread 
upon cloths than when rubbed in with the finger, and, in 
fact, the same may be said of all ointments applied with a 
view to their soothing effect. I usually bid the patient cut 

* The following directions are taken from Duhring : " The oil is to be 
mixed with a pint of water and heated, by means of a steam bath, to boil- 
ing ; the finely-powdered litharge being sifted in and stirred continually ; 
the boiling is to be kept up until the minute particles of litharge have en- 
tirely disappeared. During the cooking process a few more ounces of 
water are to be added, from time to time, so that, when completed, water 
still remains in the vessel. The mixture is to be stirred until cool. The 
ointment is difficult to prepare and requires skillful manipulation. When 
properly made it should be of a light yellowish color, and of the con- 
sistence of butter. To ensure a good article it is essential that the very 
best olive oil and the finest litharge be employed." 

To this I would add that the physician should examine each lot as made 
up, when this is possible, and he should in all cases decline to employ any 
ointment which has been on hand over a week. Although one of the 
most perfectly soothing and sedative of all ointments, unguentum diachy- 
lon is probably more apt to be ill-made or decomposed when dispensed, 
than any other, and it behooves the physician to look carefully after his 
prescription if he desires to avoid a possible catastrophe to his reputation. 



ECZEMA. 91 

out bits of soft linen cloth to fit the part to be covered, and 
then to spread the ointment upon these as thick as butter upon 
bread. When applied, they should be covered with oiled silk 
or waxed paper, for cleanliness sake. 

An ointment similar to the diachylon ointment may be made 
by adding two or three parts of olive oil to four of diachylon 
plaster, the two substances being melted together, and stirred 
until cool. The proportion of oil used will, of course, vary with 
the weather. I do not often use this preparation, as it is apt 
to be tough and stringy. It is what the average apothecary 
dispenses, however, when unguentum diachyli is prescribed. 

Among other soothing dressings maybe mentioned, finally, 
cold cream, cucumber ointment, glycerole of starch, almond 
and olive oils and dilute glycerine. The olive oil must be 
pure and of good quality; the peanut oil usually supplied 
in its place is irritating, I think. I may also remark, that 
while glycerine in full strength disagrees with many skins, 
yet, where diluted with one to three parts of water, it will 
almost invariably be found to agree. 

In papular eczema, the eruption being more discrete and 
scattered, the applications to be made must differ somewhat 
in form from those employed in vesicular eczema. Lotions 
are usually preferable, and in many cases, where the indi- 
vidual lesions are widely separated, these alone are admissible. 
Then, too, the inflammation is of a different character, and 
pursues, as a rule, a more chronic course. Soothing applica- 
tions, therefore, do not often come into use, and we are more 
apt to have recourse to stimulant remedies, as the so-called 
anti-pruritics, and chiefly tar and its derivatives. Carbolic 
acid is the most important and generally useful of these 
remedies, and the one most apt to do good in papular eczema. 
The formulae given just above will be suitable for many cases, 
only substituting water for the lotio nigra, and increasing the 
proportion of the carbolic acid when the skin will bear it. 



92 DISEASES OF THE SKIN. 

A further account of the treatment to be employed in acute 
eczema will be found under the head of the treatment of 
eczema attacking particular regions of the body. 

Chronic eczema. In some cases the treatment employed in 
the acute stage of eczema may also be made use of in the 
chronic condition of the affection ; more frequently, however, 
other and more stimulating remedies will be found more ser- 
viceable. 

Carbolic acid may be employed, either in the form of a 
lotion, as above, or as an ointment, of the strength of five to 
twenty grains to the ounce of oxide of zinc ointment, ben- 
zoated lard or vaseline. It may be relied upon as an anti- 
pruritic remedy when all others fail, and is a most valuable 
application in chronic eczema. Thymol, in the form of an 
ointment or lotion, in the strength of five to twenty grains 
to the ounce, is recommended by some writers. I have had 
very little experience with it. Tar and its preparations come 
largely into use in the treatment of chronic eczema. The 
tarry preparations must be handled with care, however, for, 
if used injudiciously, or in too great strength,. they are apt to 
inflame the skin and retard the process of cure. They are 
most apt to be useful when the disease has completely reached 
the chronic stage, and when there is more or less infiltration. 
In using tar in the form of ointment, which is ordinarily the 
most convenient method of employing this remedy, its 
strength should at first rarely exceed one to two drachms to 
the ounce. It can be increased later, if the skin requires 
and will bear increased stimulation. The two forms of tar 
commonly employed are the pix liquida of the Pharmacopoeia 
and the oleum cadini. Their effect upon the skin is appa- 
rently identical. A very convenient formula is the fol- 
lowing : — 

R. 01. Cadini ^ss 

Ung. Aquae Rosae 5jj. M. 



ECZEMA. 93 

On the scalp, fluid or semi-fluid preparations are usually 
more convenient than ointments; the following formula is 
recommended by Duhring : — 

J£. Picis Liquidae. ^j 

Glycerinae fgj 

Alcoholis f^ vj 

01. Amygdalae Amarae tt\,xv. M. 

I often use the oil of cade mixed with three or four parts 
of alcohol or of oil of almonds, as an application in some 
forms of eczema of the scalp. These preparations are not 
to be smeared on the surface, or applied on cloths, as the 
soothing remedies. Much of their efficacy depends upon 
their proper and thorough application ; they must be worked 
into the skin, in order to produce their full effect ; patients 
and attendants should be especially instructed on this point. 
In thick old patches of chronic disease, the following prepa- 
ration may be thoroughly rubbed in by means of a little mop 
of rag or candle wick tied to the end of a stick : — 

& . Picis Liquidae, 
Saponis Viridis, 
Alcoholis aa. gij. M. 

This preparation is known under the name of " tinctura 
saponis cum pice." To produce a stronger impression, 
caustic potash may be used instead of the soap, in the pro- 
portion of five to fifteen grains to each ounce of the mixture. 
The following preparation, known as "liquor picis alkali- 
nus," was introduced to the notice of the profession by 
Dr. Bulkley: — 

R. Picis Liquidae gij 

Potassae Causticae gj 

Aquae ^3 y - ^L- 

The potash is to be dissolved in the water, and gradually 
added to the tar with rubbing in a mortar. Of course, this 



94 DISEASES OF THE SKIN. 

preparation is much too strong to be used undiluted, except- 
ing in the rarest cases. As a lotion, it may be diluted with 
from eight or more parts of water at first, down to two parts 
after a little trial ; care should be taken not to make the 
lotion too strong at first. The liquor picis alkalinus may 
also be combined with ointment, from one to two drachms 
to the ounce. 

Soaps play an important part in the treatment of some 
forms of eczema. In ordinary cases, plain white castile soap 
is all that is required for cleansing purposes; and the less 
soap that is used beyond what is necessary for this purpose 
the better, as a general thing. Strong alkaline soaps are 
used in eczema, for their remedial effect, being particularly 
employed when some infiltration is to be removed, or when 
a stubborn and rebellious local patch of disease requires 
strong stimulation. Of these, the most generally useful is 
that known as Hebra's soap, green soap, or as it has been 
called in other parts of this work, " sapo viridis," a strongly 
alkaline potash soap. (See Sapo viridis?) It may be employed 
alone or in the form of an alcoholic solution, known as 
" spiritus saponis kalinus" : — 

R. Saponis Viridis J§ ij 

Alcoholis fjjjj. M. 

Dissolve with the aid of heat, and filter. 

It may be scented with lavender or other perfume if de- 
sired. This wash is very useful also for cleansing patches of 
eczema when covered with accumulated, crusts and scales. 

Under ordinary circumstances, and unless left in contact 
with the skin with a particular object in view, these stronger 
soaps should be washed off at once, and some oleaginous or 
fatty substance applied. Much mischief is sometimes done 
by allowing caustic soaps to remain in contact with the skin. 
Some years ago, when sapo viridis first came into vogue, I 
saw case after case in which this alkali had been applied 



ECZEMA. 



95 



without knowledge or thought of its properties, as if it 
had been an ointment, that is, smeared on the inflamed 
skin and allowed to remain, to the great detriment of the 
patient. 

Sapo viridis is particularly useful in extensive infiltrated 
eczema rubrum of the leg and other parts. It should be well 
rubbed into the affected patches, by means of a flannel rag, 
until considerable smarting, abundant serous discharge, and, 
perhaps, slight bleeding are induced. The soap is then to be 
completely washed off with pure hot water, the patch of dis- 
ease lightly dried with a soft cloth, and some soothing oint- 
ment, by far most preferably unguentum diachyli, is applied, 
spread upon strips of cloth. This process is repeated once, 
or sometimes even twice, daily, and when it can be properly 
carried out is a rapid and efficient method of dealing with 
this form of eczema. In old, infiltrated patches of eczema, 
and in eczema of the palms particularly, solutions of caustic 
potash, ten to forty grains, or even a drachm, to the ounce, 
may be employed to advantage. The stronger of these must 
be used by the physician himself, and may not with safety be 
entrusted to the patient or to his attendants. The application 
should be made with a little mop tied to a stick, or occa- 
sionally with a bit of wood. The parts should be immediately 
bathed with cold water, or covered with cold-water com- 
presses, and after a short time a soothing ointment may be 
applied. This procedure reduces infiltration, and stops itch- 
ing very effectually, but it is a sharp weapon, and not to be 
used rashly. Pushed too far, there is danger of causing 
local sloughing, with subsequent scars. It should not be 
used more than once or twice a week under ordinary circum- 
stances. 

Other remedies for the chronic forms and stages of eczema 
maybe mentioned, as follows: Mercurial preparations are 
particularly valuable, especially when the disease is confined 



96 DISEASES OF THE SKIN. 

to a small area. When covering a considerable surface, mer- 
curials should be used with care, or not at all, both on account 
of the fear of over-stimulation and for fear of absorption with 
resultant salivation. Calomel is the most generally useful of 
the mercurial preparations; it may be employed according to 
the following formula: — 

R. Hydrarg. Chloridi Mite gr. x-xxx 

Ung. Zinci Oxidi, 

Ung. Petrolii aa ^ss. M. 

The red oxide of mercury in ointment, of the strength of 
five to thirty grains to the ounce, is also often very useful ; it 
constitutes a chief ingredient, I believe, in some of the best 
known quack "tetter" ointments. Somewhat milder is the 
ointment of ammoniated mercury, which may be employed 
of the same proportionate strength to advantage, in the pus- 
tular eczemas of children. Sulphur is also a highly useful 
application in some forms of eczema, particularly when there 
is a moist surface, or when its "cornifying" influence is re- 
quired to regenerate the horny epithelium of the skin. It 
may be used in the form of ointment, of the strength of one 
to two drachms to the ounce of cold cream, in chronic eczema 
rubrum, occurring in patches ; also, occasionally, in chronic 
pustular eczema, particularly about the hands. It should 
usually be used in a mild strength at first, and after a few 
days' use should generally be substituted, for a time at least, 
by some other preparation. A combination of the officinal 
tar and sulphur ointments sometimes acts happily in old 
chronic eczemas with much itching and infiltration. Boric 
and salicylic acids have been highly recommended by authors 
of repute during the past few years. As to the former, I 
have used it in saturated solution in the eczema of infants 
with satisfaction ; but have not had much experience in its em- 
ployment elsewhere. It would seem more useful in the acuter 
forms of eczema. The following paste containing salicylic 



ECZEMA. 97 

acid is a very excellent preparation, but, like the boric acid 
solution, is perhaps better fitted for employment in the acute 
than in the chronic forms of eczema. It will come into use 
very conveniently in that class of cases where ointments are 
indicated, but where there is some idiosyncrasy which pre- 
cludes their use: — 

R. Acidi Salicylici gr. x 

Pulvis Zinci Oxidi, 

Pulvis Amyli aa ^ij 

Vaselini ^iv. M. 

This is an excellent ointment for use in hot weather. In 
winter it is a little stiff, and I think the proportion of starch 
might conveniently be reduced for cold weather. 

A few years ago Mr. Squire, of London, brought forward 
the preparation known as glycerole of the subacetate of lead, 
as a remedy in chronic eczema. His formula is as follows : 
Acetate of lead, 5 parts; litharge, 3^3 parts; glycerine, 20 
parts, by weight'. Mix and expose to a temperature of 35 o° F. , 
and filter through a hot water funnel. The clear viscid fluid 
resultant contains 129 grains of the subacetate of lead to the 
ounce. This is used as a stock, from which the preparations 
employed are made by dilution with simple glycerine. I 
have used this preparation quite extensively in the treatment 
of chronic eczema rubrum of the legs, particularly when the 
disease is extensive, of a dusky red hue, accompanied by 
weeping, oedema and a varicose condition of the veins. Also 
in eczema of the palms and soles. In eczema of the legs the 
glycerole stock may be used diluted with three parts of pure 
glycerine. Strips of linen soaked in this preparation are 
applied to the affected limb, and covered with wax paper and 
a bandage, the dressing being changed once or sometimes 
twice daily. This method of treatment may be employed to 
advantage in many cases when the treatment by means of 
sapo viridis and unguentum diachyli cannot be carried out. 



98 DISEASES OF THE SKIN. 

In eczema of the palms and soles the following ointment 
gives good results : — 

R. Glycerol. Plumbi Subacetatis f,o ss 

Glycerinse f 3 iss 

Ung. Aquae Rosae ^j 

Cerse Albae q. s. M. 

This is to be made into a tolerably firm ointment, and 
applied to the affected parts. It is better to precede its use 
with the application of solutions of caustic potash, and it 
should be spread thickly upon narrow strips of linen, and 
placed in close apposition to the affected parts, being covered 
with wax paper, to prevent soiling. 

For obstinate, circumscribed patches of eczema, blistering 
with cantharidal collodium will sometimes be found bene- 
ficial. With the same object, strong solutions of carbolic 
acid in alcohol, tincture of iodine, and solutions of nitrate 
of silver, or even the solid stick, may be employed. Vulcan- 
ized india rubber has been used extensively in the treatment 
of eczema, and may be employed with advantage, both as a 
protective against atmospheric influences, as a preparative for 
other applications, and as a direct therapeutic agent. In the 
form of Martin's solid rubber bandage, it is of great use in 
varicose eczema rubrum of the leg. It is apt to give rise to 
great itching, and even pain, when applied continuously upon 
the lower limbs, and for this reason it is well to have the 
bandage applied in the morning on rising, and to be worn 
during the day only. On retiring at night, the bandage is 
to be removed, and the limb plunged quickly into water as 
hot as can be borne. Removed from this in a few moments, 
it is wiped gently dry and the surface dusted with starch 
powder, and loosely covered with linen cloth for the night. 
If the itching is very severe, a carbolic acid lotion may be 
substituted for the powder. Under this treatment rapid im- 
provement is usually observed ; and sometimes no further 



ECZEMA. 99 

treatment is required. Rubber cloth in sheets, rubber masks 
and finger-stalls, are also often employed in the various forms 
of eczema with advantage. 

Having now spoken of the acute and chronic forms of 
eczema in general, it will be advantageous to next consider 
this disease as it is met with in different localities. 

Universal eczema is very rare ; when it does occur it is 
usually erythematous or squamous. Its history in these cases 
will serve to bring out one or another of the points mentioned 
in discussing the general diagnosis of the disease, and so lead 
to its identification. Eczema of the scalp is usually erythe- 
matous, vesicular or pustular. The first variety rapidly runs 
into the squamous, the scalp being more or less covered with 
red, scaly patches, which are very itchy. The pustular 
variety is common among children. The pustules commonly 
come out in great numbers about the hair follicles. They 
soon rupture, and the liquid, oozing over the skin, forms 
yellowish-green crusts, sometimes amounting to thick masses. 
The hair becomes matted and caked ', the scalp, if not 
cleansed, gives out a very offensive odor ; and the disease, 
unless checked by proper treatment, may last from a few 
weeks even to years. The itching is usually not so decided 
in this as in other forms of eczema. Sympathetic enlarge- 
ment of the lymphatic glands about the back of the neck 
and behind the ears is common in this form of eczema, and 
in the case of children often gives rise to great anxiety on 
the part of parents. The glands never suppurate, and the 
patient's friends may be assured, with confidence, that, as the 
irritation and inflammation about the scalp subside, the 
glandular engorgement will spontaneously disappear. Small 
abscesses often complicate the eczema of the scalp in unhealthy 
children. Pediculi also are very frequently present, and the 
scalp should be examined for the insects or their nits in all 
cases of pustular eczema. A patch of pustular eczema occur- 



100 DISEASES OF THE SKIN. 

ring in the occipital region, especially in neglected and ill- 
nourished children, almost invariably points to the presence 
of pediculi as a cause. When present, they should at once 
be removed by the means described under Pediculosis capitis. 
Eczema of the scalp may be confounded with psoriasis, sebor- 
rhcea, favus, syphilis and tinea tonsurans. From psoriasis of the 
head eczema may be distinguished by the symptoms mentioned 
in the general diagnosis of the disease. Pityriasis sometimes 
resembles eczema capitis very closely, but the pearly color of 
the scales and the not unfrequent combination of more or less 
seborrhcea with the pityriasis, making the scales greasy, as 
also its diffusion, and the history of the case, are important 
elements in distinguishing eczema from this disease. Other 
points have been touched upon earlier. Pustular eczema 
alone is likely to be mistaken for favus, but the mustard or 
canary color of the favus crusts, their commonly cup-shaped 
outline and the dry, pulverulent consistence of the masses of 
fungus, together with the microscopic appearance, will be 
sufficient to distinguish it from eczema. As before mentioned, 
certain syphilitic diseases of the scalp may be mistaken for 
eczema. The history of the case, with the characteristic 
symptoms above given, are ordinarily sufficiently distinctive. 
Erythematous or squamous eczema may sometimes be mis- 
taken for tinea tonsurans. The patches of eczema, however, 
are not attended with loss of hair. In ringworm of the scalp 
the hairs are broken off uniformly about an eighth or a quar- 
ter of an inch beyond the scalp. The hair has a nibbled ap- 
pearance. The patches in ringworm are apt to be roundish 
in outline. In eczema they are irregular. The color of the 
scalp is of a leaden hue ; while in eczema it is reddish, and 
has more the appearance of inflammation. The itching in 
eczema is marked. In tinea tonsurans it is slight. A history 
of contagion is frequently found in connection with tinea 
tonsurans. 



ECZEMA. 101 

The treatment of eczema capitis will, of course, depend 
upon the variety and stage of the affection in each case. In 
pustular eczema the crusts must first be removed by means of 
hot water and soap, preceded, if necessary, by thorough 
saturation with olive or almond oil, to soften and loosen the 
crusts. Sometimes the scalp must be well saturated with oil 
and covered with a cap over night ; and perhaps the process 
must be repeated ; at all events, the crusts must be removed 
before any applications are made. Occasionally the oil alone 
appears to exert a curative influence, but usually more decided 
treatment is required. The hair in children, boys and men 
may be cut short, especially when lice are present. In women 
this sacrifice is not necessary, and should not be permitted. 
Now and then, however, we meet cases where women are 
suffering with severe and neglected eczema due to pediculosis 
of long standing, and where the hairs are so matted and glued 
together that we are obliged to have recourse to the scissors. 

As to medicinal applications : in inflammatory cases black 
wash or one of the carbolic acid lotions may be applied 
with a sponge or cloth for ten or fifteen minutes at a time, 
morning and evening, and these may be followed each time 
by an oily preparation. If ointments can be used, the fol- 
lowing are of value : — 

R. Bismuthi Subnitrat £j 

Unguent. Petrolii If j. M. 

Or this, 

R. Hydrarg. Ammoniat gr. x-xx 

Unguenc. Petrolii ^j. M. 

The following is somewhat more stimulating. It appears 
to have a drying effect when there is discharge : — 

R. Hydrarg. Chlor. Mite gr. xx-xl 

Unguent. Petrolii %]. M. 

A small portion only should be applied at once, but this 
should be rubbed in thoroughly. When a stimulant effect is 



102 DISEASES OF THE SKIN. 

desired, an ointment of the red oxide of mercury, ten to 
twenty grains to the ounce, may be employed. The ammoni- 
ated mercury ointment is particularly useful, in cases where 
the eczema is due to the presence of lice. 

When still stronger stimulation is required, especially when 
exudation has ceased, and the scalp is red and scaly, one of 
the following ointments may be employed : — 

R, Ung. Hydrarg. Nitrat 3^ j-iv 

Ung. Petrolii giv. M. 

Or, 

R. Picis Liquidae gj 

Vaselini 3J. M. 

As these cannot be applied when the hair is long, a fluid 
preparation must be employed : — 

R. 01. Cadini f^ssadfgj 

01. Amygdalae ad f-^j. M. 

Alcohol may be substituted for the oil when the hair is 
quite thick. In some cases, when there is scaly eczema of 
the scalp with some tendency to greasiness, and the occur- 
rence of seborrhoea, the following ointment acts happily : — 

R. Acidi Tannici gj 

Ung. Petrolii |j. M. 

When the hair is long, glycerine and alcohol in equal 
proportions, may be substituted for the vaseline. 

Eczema of the/ace is more apt to be met with in children, 
(see Eczema infantile), but is also found in adults, on the 
cheeks and elsewhere. The form of eczema found in adults 
is usually the erythematous, on the cheeks, nose, forehead, 
and sometimes extending around to the ears and down the 
neck. The skin becomes bright or dusky red, with intense 
burning and some itching. It becomes thickened, infiltrated 
and stiff, with some scaliness. This form of eczema is more 
apt to occur in winter, and among persons exposed to cold 



ECZEMA. 103 

and wind. In addition to such general means of treatment 
as are called for by the patient's condition, active local mea- 
sures should be used. Lead water lotions are valuable in the 
acute stage, and also black wash. Black wash should be 
sopped on the skin, or laid on by means of rags saturated 
with it, and renewed hourly. This may be followed by an 
ointment, especially if the patient must move about and 
cannot keep the wash in contact. The following is a very 
good preparation : — 

R. Pulv. Zinci Oxidi 3J~B i) 

Sevi Purificati..... 3^j _ 9ij 

Adipis 3 iv ~3 U 

Pulv. Ulmi Fulvas q. s. M. 

Or oxide of zinc ointment with equal part of vaseline 
may be employed. 

In order to protect the skin from cold air, which is poison- 
ous when the skin is in this condition, I am accustomed to 
recommend the use of the following paste : — 

R . Tragacanth, 

Glycerinse aa 3 iv 

Boracis ^ss 

Aquae Destillat q. s. M. 

With these materials, a thin, adherent, quickly drying 
paste may be made, with which the skin of the face may be 
painted just before going out of doors. This is almost or 
quite' invisible, and yet acts as a perfect protective. On 
returning home it may be washed off readily with a little 
warm water, and then the lotions and ointments may be 
applied. This is worth remembering, .because not every 
one can stay at home, day after day, and keep applica- 
tions constantly to his face, and it is well to be prepared with 
some such alternative, which if it does little good yet pre- 
vents much harm to the skin. 

As soon as possible the soothing applications should be 



104 DISEASES OF THE SKIN. 

changed for lotions and ointments containing tar and car- 
bolic acid. The carbolic acid wash may be tried even when 
the eruption is at its height, being more apt to be useful 
if itching, rather than burning, should be the prominent 
symptom. The formula is given a few pages back. Water 
may be substituted for the lotio nigra. 

The proportion of carbolic acid may be increased or 
diminished as the case requires. There is a solution of coal 
tar which is known as "liquor carbonis detergens," and 
which is miscible with water, which is an excellent lotion for 
use in this form of eczema ; it should be employed in the pro- 
portion of one part to eight of water or stronger. When 
ointments are borne, the following is useful in very many 
cases. I almost always try it before using other prepara- 
tions : — 

R. Picis Liquidse gss-^ij 

Ung. Aquae Rosse ^j. M. 

Now and then fissures and cracks form in the infiltrated 
skin, especially about the alae nasi. The following pigment 
is very efficient in healing these, and may often be used as 
a protective over other parts of the face, when there is no 
objection to the discoloration : — 

R. 01. Cadini gj 

Liq. Gutta Percha, see Collodii. ^j. M. 

Let a brush be put in the cork, and let the patient paint 
the skin over several times a day. This pigment has the 
advantage over ointments, that it cannot be rubbed off. 

Eczema of the lips is ordinarily accompanied by swelling, 
redness, heat, infiltration, slight scaliness and fissures. The 
muco-cutaneous surface or the skin outside may be attacked, 
and the symptoms and treatment differ according to the seat 
of the eczema. Eczema of the lips is to be distinguished 
from herpes and syphilis. Herpes runs a distinct, short 



ECZEMA. 105 

course, and is composed of discrete, well-marked vesicles or 
groups of vesicles. Eczema is more obstinate, and covers a 
larger surface. Syphilis occurring about the mouth usually 
either assumes the form of circumscribed, more or less ir- 
regular erosions on the inside of the lip, or else is seen 
localized in the angles of the mouth, forming a more or less 
deep fissure and secreting a puriform fluid. Eczema of the 
lips, especially when occurring on the muco-cutaneous surface, 
is difficult and painful to treat. Solution of potassa, twenty 
grains to the ounce, is of use when there is infiltration. The 
muco-cutaneous surface should be carefully dried before it is 
applied, and afterwards, to prevent running. Ordinarily 
milder preparations are best. The following is a useful com- 
bination : — 

R . Acidi Phosphoric!, dil., 

Glycerinae, 

Syrupi aa f^ ss - M. 

SlG. — Apply to parts three times daily. 

The same formula, with the addition of enough water to 
make six ounces, may be given simultaneously in teaspoonful 
doses thrice daily. When a dry, wrinkled, scaly condition 
exists, G. H. Fox suggests the use of an ointment containing 
five grains of thymol to the ounce of cold cream. 

When the outer edge of the lip is affected the following 
ointment is useful : — 

U . Zinci Oxidi, 

Mellitis aa 9 ij 

Olei Amygdalae gvj 

Cerae Flavse gij. M. 

In winter a condition analogous to eczema produces 
annoying fissures of the lip, which may be treated by moist- 
ening the fissure and applying a pointed stick of nitrate of 
silver. Afterwards the compound tincture of benzoin may 
be painted on as a protective. Another procedure in chronic 
8 



106 DISEASES OF THE SKIN. 

cases is to forcibly tear open the crack a short distance and 
then rub in, by means of a bit of stick, a minute quantity of 
strong red oxide of mercury ointment (forty to sixty grains 
to the drachm). 

There is a form of eczema occurring on the upper lip, about 
the opening of the nostril. This will be considered under 
eczema of the beard. 

Eczema of the eyelids often occurs in scrofulous and badly- 
nourished children, and less frequently, among adults also. 
The follicles of the eyelashes are involved, small pustules 
forming, which dry into crusts, gluing the edges of the lids 
together. These are usually more or less red and swollen. 
Conjunctivitis may or may not be present. The treatment 
varies, according to the severity of the case. Mild cases 
require no more than the application of a weak nitrate of 
mercury ointment, made of the officinal ointment diluted 
with three to six parts of cold cream, or an ointment of ten 
grains of red oxide of mercury to the ounce of cold cream. 
In severe cases the eyelashes should be extracted, the edges 
of the lids carefully dried and then touched with a camel's 
hair pencil moistened with a drop of a ten-grain-to-the-ounce 
solution of caustic potassa. This application is to be wiped 
away immediately and the effect neutralized by the applica- 
tion of cold water. The operation may be repeated every 
day until the infiltration, exudation and itching subside, after 
which one of the stimulating ointments just mentioned may 
be used to complete the cure. 

Eczema of the beard is sometimes excessively stubborn and 
annoying. Pustules, usually seated about the hairs, form 
with great rapidity and persistence, and are followed by yel- 
lowish or greenish crusts, often matting the hairs together. 
Usually the affection is confined to a limited locality, as the 
corner of the upper lip, near the commissure, or just at the 
opening of the nostrils ; but occasionally the whole beard 



ECZEMA. 107 

may be involved, and the disease may extend to other parts 
of the face. In this respect the affection differs from sycosis 
(see Sycosis), which is always limited to the hair follicles. 
The latter is also a deep process, involving the follicles them- 
selves, while eczema barbae is essentially superficial, occupy- 
ing the surface of the skin alone and taking in the hair follicles 
only incidentally. Papules and tubercles, not uncommon 
in sycosis, are absent in eczema barbae. The two affections 
do, however, often resemble one another very closely. 

Tinea sycosis (see Tinea sycosis) is sometimes mistaken for 
eczema barbae ; it is important to distinguish between the two 
diseases. Crusts are generally abundant in eczema ; in tinea 
sycosis they are generally (though not always) scanty. When 
the crusts are removed the eczematous surface is smooth, while 
in tinea sycosis it is rough, uneven, tubercular and lumpy — a 
very important point. The hairs in eczema are usually firm 
in their follicles, and the attempt to remove them causes pain, 
even when there is a good deal of suppuration about the root. 
In tinea sycosis, on the other hand, the hairs come away with- 
out the least pain or difficulty; they are often crooked, but 
are usually quite smooth and dry, while the hairs of eczema 
are surrounded by the glutinous root sheath. Above all, the 
hairs in tinea sycosis almost invariably contain the character- 
istic fungus (see Tinea sycosis) ; besides which, the source of 
contagion in this highly contagious disease can frequently be 
traced out. Finally, patches of characteristic ringworm not 
unfrequently can be seen on the neighboring skin. 

The treatment of eczema of the beard should be prompt 
and energetic. The crusts must first be removed with oil 
or poultices followed by soap and warm water, and then the 
beard must be carefully shaved. This is a painful operation 
when first performed, and patients often rebel against it. 
It is well to be firm, however, and it is unsafe to take the 
responsibility of a case, unless the patient complies with these 



108 DISEASES OF THE SKIN. 

directions. After the first time, shaving is much less painful, 
and patients do not object. Ointments and applications can- 
not be brought into intimate contact with the surface when 
there are hairs growing upon it. In the acute stage, the 
treatment by sapo viridis and unguentum diachyli, as de- 
scribed under the general treatment of eczema, is best. 
Later, a weak sulphur ointment, of one drachm to the ounce, 
or the sulphur and tragacanth wash (see Acne), may be 
employed. 

Eczema of the ears may occur in any form, and may 
involve either the outside or the meatus. In the acute forms 
and stages the ears are red and swollen, and they burn and 
itch severely. The disease, when it involves the meatus, may 
cause temporary deafness from occlusion by large and abundant 
epidermic flakes and scales. Ointments, as a rule, are most 
useful in eczema of the ears, though in the acute stages, black 
wash, or the other washes, may first be employed, as in the 
general treatment of acute eczema. When there is a deep 
crack behind the ear, of long standing, sapo viridis may be 
briskly rubbed in, followed by an ointment containing tar 
or calomel, a drachm to the ounce. This is a good com- 
bination : — 

R. Picis Liquidse gj 

Ung. Zinci Oxidi ^j. M. 

Or calomel may be added to this formula. When the 
meatus is involved, ointments, etc., being used, the opening 
may become gradually clogged with debris, and deafness, often 
quite alarming to the patient, may result. In these cases 
the meatus is to be carefully syringed out with warm water, 
containing a little borax, sodium carbonate, or common 
salt, in order to remove all the wax, epithelium, grease, etc. 
Oil of sweet almonds may be dropped into the meatus first, 
to soften the mass. Care must be taken in these manipu- 
lations, and especially in making applications, not to injure 



ECZEMA. 109 

the membrana tympani. The crusts being removed, and the 
meatus gently dried, the affected parts may be touched with 
a solution of nitrate of silver, two to three grains to the 
ounce, and dry charpie applied, or if there is much oozing, 
cold cream in small quantity. If the skin is infiltrated, a 
solution of potassa, ten grains to the ounce, may be applied, 
by means of a camel's-hair pencil carefully stripped before 
introduction, so as not to leave a drop which may run down 
to the tympanic membrane. These applications may be made 
every day or two, and as the acute symptoms pass off, an 
ointment of tannic acid, one drachm to the ounce, may be 
substituted for the cold cream. Eczema occurring about the 
ears, and particularly in the meatus, is apt to be stubborn. 

Eczema of the genitals is one of the most painful and dis- 
tressing forms of the disease. In the male, the penis or the 
scrotum alone may be involved, or both together. The latter 
is more commonly the seat of the disease, and the tissues of 
the skin here become greatly thickened, swollen and infil- 
trated. Moisture, crusts, and painful fissures along the folds 
of the skin are often present. Itching is a severe and promi- 
nent symptom, and the disease is apt to be very chronic. 
In the female the labia and even the vagina may be invaded. 
The affection here is even more distressing than in the male. 
Itching is violent and causes extreme misery. The diagnosis 
is not difficult. Pruritus alone is apt to be mistaken for 
eczema of the genitals, and here the absence of visible 
primary lesions will decide the character of the case. The 
itching comes first in pruritus, and then the skin is torn and 
bleeding, from the scratching. 

Sometimes eczema of the genitals yields quickly to treat- 
ment ; this is when it is recent and superficial ; chronic eczema 
with thickening and infiltration is often obstinate to an ex- 
treme degree. 

In the acute and superficial form, simple or medicated 



110 DISEASES OF THE SKIN. 

warm baths are often grateful and give much relief. The 
following is a fair sample of the method of making up these 
baths : — 

R. Potassii Carbonat ^iv 

Sodii Carbonat ^ij 

Pulv. Boracis 3 ij. M. 

Dissolve in a quart or so of water ; add four to six ounces 
of dry starch, placed beneath the water in the hand, which is 
then opened and beaten through. Six to eight ounces of 
glycerine may then be added if thought desirable, and the 
whole mixed in with about thirty gallons of hot water in a 
long bath tub. The patient remains in the bath for fifteen to 
twenty minutes. On coming out the parts are to be carefully 
dried without rubbing, and then at once thickly dusted with 
powdered subnitrate of bismuth, or wrapped up in an ointment 
composed of one part of cod-liver oil to two parts of suet. 

When baths cannot be taken, or even when these are em- 
ployed, it will often be found advantageous to use lotions of 
lead water or black wash, or the fluid extract of grindelia 
robusta, two drachms in a pint of water. If the patient is 
obliged to go about his work or business, it will be well, if he 
be a man, that the part be wrapped or supported in fine linen 
wrappings, to protect it. One of the various dusting powders, 
as nitrate of bismuth, lycopodium, magnesia, etc., may be 
dusted on, or if powders are found too drying, a little vase- 
line may be smeared over the surface. In both men and 
women it is important to keep adjacent parts separate from 
one another, as the heat and moisture engendered infallibly 
make the disease worse. 

Where there is infiltration the treatment must be different. 
Whatever applications are made, however, will do more good 
if the parts are first bathed with water as hot as can be borne. 
The sapo viridis and unguentum diachyli treatment, described 
above, under the head of general treatment, is a most excel- 



ECZEMA. Ill 

lent method for use in chronic and indurated eczema of the 
genitals, when it can be had. When there is considerable 
itching carbolic acid wash — acid carbolic, 3^ iij ; glycerine, 
%}; aquae, Oj — is of advantage. It is particularly useful in 
eczema of the female genitals, and its application, which may 
be practiced at intervals of a few hours, should be preceded, 
when possible, by bathing with hot water. In eczema of the 
scrotum, when there is much itching, the following applica- 
tion may be employed : — 

R. Argenti Nitrat gr. x-xxx 

Spiritus JEth. Nit fjj. M. 

This is to be painted on the parts, and will serve to protect 
them ; if found too stiff, some ointment may be applied as 
soon as the pigment is dry. Stimulating ointments, mercu- 
rial, tarry, etc., as given above, may be employed from time 
to time, as required, and one thing should be tried after 
another until relief is gained ; for in this form of eczema, 
more than in any other, perhaps, the treatment must, of 
necessity, be largely empirical and tentative. 

Eczema of the anus is not very common — pruritus of this 
region being usually mistaken for this disease — but when it 
occurs, may cause much infiltration and Assuring, with not 
unfrequently involvement of the neighboring parts. It usually 
assumes the erythematous form, and when fissure results great 
pain is experienced on defecation. On account of this, 
constipation from over-retention of the faeces is commonly 
present, with the effect of heightening the discomfort and 
pain caused by the passage of the stools. Itching and burning 
sensations, worse at night on going to bed, and in severe 
cases pain on defecation — these are the chief symptoms of 
eczema ani. The treatment is, in general, the same as that of 
infiltrated eczemas in other localities. Tar ointments in 
various proportions are very useful. The following formula 
gives the tar in the least offensive form possible — 



112 DISEASES OF THE SKIN. 

R. Picis Liquidas £j 

Medullse Bovis gvj 

Cerae Albse gj 

01. Rosse TT\v. M. 

Almond oil containing twenty per cent, carbolic acid forms 
a cleanly and not disagreeable application. It may be rubbed 
in with the finger every night on retiring. Even when the 
muco-cutaneous surface is abraded and fissured, this oil gives 
relief, while many applications pain severely. When there 
are deep fissures, these should be split open and touched with 
the nitrate of silver stick, the tar ointment being subsequently 
applied. The parts should be kept scrupulously clean, and 
the patient should be exhorted not to scrape and dig at the 
skin, but to fly to his ointment or oil when the attack comes 
on, and especially to keep these close at hand when undress- 
ing for the night. If there is any tendency to congestion 
and moisture about the nates and perineum, these should be 
powdered with starch or astringent powders. Aperients, by 
permitting the passage of the faeces in a softened condition, 
and also possibly by relieving the circulation in the hemor- 
rhoidal veins, may often be of service. 

Eczema intertrigo resembles erythema intertrigo (see Ery- 
thema intertrigo), but shows the characteristics of eczema. The 
parts should be dusted frequently with astringent powders, kept 
from rubbing, if possible, by the interposition of lint or cloth, 
and rest, when possible, should be enjoined. Sometimes 
astringent lotions are useful. 

Eczema of the breasts may occur about the nipple or on 
the lower edge of the breasts. The former variety is often 
brought about or kept up by nursing. The diagnosis, es- 
pecially from syphilis and from Page? s Disease (see Paget' s 
Disease of the Nipple), which is very important, is to be made 
by exclusion. Eczema occurring in this locality shows the 
infiltration, redness, exudation, burning, itching, etc., char- 



ECZEMA. 113 

acteristic of the affection. The sapo viridis and unguentum 
diachyli treatment, or that by solutions of caustic potassa, is 
the best when there is much infiltration. The treatment in 
every case should be decided and vigorous. When fissures 
of the nipple occur in nursing women, leaden shields may be 
used and the cracks in the nipple moistened, touched with 
nitrate of silver stick (an excessively painful operation for the 
moment), and painted with compound tincture of benzoin. 
By this means cracks in the nipple can often be healed up 
while the child is nursing. When eczema occurs about the 
lower edge of the breast it generally takes on the form of 
eczema rubrum or eczema intertrigo, and is in part due to a 
pendulous condition of the mammae. The usual treatment 
of lotions, black wash, astringent powders, and the inter- 
position of lint or absorbent cotton will work a cure. 

Eczema of the umbilicus is usually moist and fissured. A 
disagreeable odor generally accompanies the affection in this 
locality, and there are scales and crusts. The disease is apt 
to be mistaken for syphilis if it occurs only in this locality, 
but in syphilis ulceration usually takes place, and the smell 
is more than disagreeable \ it is positively offensive. 

Eczema of the legs is a very common form of the disease, 
especially among old people. The erythematous and vesicu- 
lar varieties are commonest at the beginning, but these soon 
change to eczema rubrum or weeping eczema. The affection 
occurs in one or more patches of various size, the whole leg 
being not unfrequently involved. When it comes under 
notice it has generally lasted some time ; the skin of the leg 
is smooth, shiny, dusky red or violaceous and unbroken ; or 
it may be moist and weeping, or covered in part or wholly 
with scales and crusts. There is always a good deal of thick- 
ening and infiltration, with burning and itching to an extreme 
degree. Varicose veins often accompany this form of eczema, 
and varicose ulcers are not uncommon. Eczema rubrum 



114 DISEASES OF THE SKIN. 

sometimes occurs in elephantiasis of the legs ; here it is 
secondary to the other affection. The diagnosis of eczema 
of the leg is not difficult. Ulcers, when present, are to be 
distinguished from syphilitic ulcers. The treatment of eczema 
of the leg must vary with the nature of the case. In moist, 
weeping eczema the sapo viridis and unguentum diachyli is 
the best treatment when it can be carried out. Next to this 
is the treatment by means of glycerole of the subacetate of 
lead. Both forms of treatment have already been described. 
Of late I have used, with great satisfaction, a paste suggested 
by Unna. It is composed as follows : — 

R . Kaolin., 

01. Lini. (seu Glycerinae). .aa.. gvj 

Pulv. Zinci Oxidi, 

Liq. Plumbi Subacetat...aa... ^ ss. M. 

This forms a thick, creamy liquid, which dries with toler- 
able rapidity on exposure to the air. It is best preserved in a 
bottle with a large brush in the cork. This prevents evapo- 
ration and permits the ready application of the remedy. A 
thick coating is painted on the skin and allowed to dry, which 
usually occurs in a few moments, or if it does not dry quickly 
enough a little powdered kaolin or starch may be dusted over 
the surface by means of a whisp of cotton. A bandage is 
then applied firmly from the toe to the knee, and the dressing 
allowed to remain in place for twenty-four hours. At the end 
of that time, the bandage being removed, the dried paste can 
be readily detached. When it sticks closely to the skin it is 
better not to tear it off, but to paint over the whole limb. 
This process is repeated daily, the area covered diminishing 
with the healing up of the disease, until, finally, pigmentation 
occurs. When enlarged or varicose veins occur in connection 
with eczema of the leg, particular pains must be taken to sup- 
port the vessels and to give tone to the circulation. The 
patient should sit or lie with the limb in an elevated position, 



ECZEMA. 115 

and should never permit it to hang down. Walking exercise 
may sometimes be taken in moderation with benefit, if the 
limb has been supported by an elastic stocking, or by one of 
Martin's rubber bandages. Bandages of one kind or another 
should always be employed in eczema of the leg, both to 
support the dressing properly, and, as has been said, to give 
tone to the vessels. Too much stress cannot be laid on the 
importance of attending to the condition of the circulation 
in eczema of the leg. The rubber bandage is particularly 
useful when there are ulcers present. It should be applied 
directly to the limb, care being taken to exercise firm and 
even, but not too severe pressure. At night the bandage 
should be removed and dropped into a bucket of cold water, 
from which it can be removed in the morning and dried pre- 
vious to re-application. The leg should be dusted with 
starch, or dried with a towel ; or it may be bathed with hot 
water or carbolic acid, if there is much itching, and then is 
to be wrapped up loosely in a muslin bandage, or cloth, for 
the night. 

Eczema of the hands may attack either the back or the 
palm. The appearance and course of the disease is so differ- 
ent, however, in one case or the other, that they must be 
considered separately. Eczema vesiculosum is the variety 
most common on the backs of the hands, and on the backs 
and sides of the fingers. Sometimes the pustular variety is 
found, and occasionally fissured eczema about the knuckles. 
The vesicular form of eczema is not unlike that found in 
other localities, excepting that large blebs occasionally form. 
It may be acute or chronic, and in some cases the nails are 
also involved in the disease. It is apt to occur as a result of 
exposure to acids, alkalies, brickdust, etc. The diagnosis 
between eczema and scabies of the backs and sides of the 
fingers and hands is sometimes very difficult. In scabies the 
peculiar burrow of the itch insect, a short, irregularly curved, 



116 DISEASES OF THE SKIN. 

beaded, black line, a quarter of an inch in length, is often 
present, and the vesicles are few in number and scattered. 
In eczema, on the other hand, the vesicles are numerous and 
closely grouped. In scabies the vesicles are firm, and usually 
remain unruptured until they are opened by mechanical 
means. In eczema the vesicles usually rupture spontaneously, 
at an early period. The vesicles of scabies commonly ex- 
hibit through their summits, a fine, dark, irregular line, 
made up of points, being the original burrow in the epidermis 
which has been raised by the formation of the vesicle. This 
is, of course, wanting in eczema. The occurrence of scabies 
elsewhere over the body, will also assist in the diagnosis. 
Vesicular eczema of the backs of the hands may also be 
confounded with the rare disease known as dysidrosis or 
pompholyx. (See Dysidrosis). Eczema of the backs of the 
hands, and particularly eczema of the fingers, is apt to be 
very intractable, sometimes recurring every year or oftener, 
at regular intervals. In the acuter forms of vesicular eczema 
of the backs of the hands, lotions, as black wash, and par- 
ticularly a lotion of two to four grains of the sulphate of zinc 
to the ounce of water, are useful in the more chronic form of 
the disease. Stimulating ointments commonly answer the 
best purpose in the chronic form. When the case is chronic 
and not very extensive, the vesicles may be ruptured by an 
application of solution of caustic potassa, twenty to forty 
grains to the ounce, applied with a pointed stick, or brushed 
quickly over the surface and washed off. The application is 
to be followed by a soothing ointment. India rubber finger- 
stalls are sometimes employed with success. Eczema of the 
backs of the feet differs in no essential from eczema of the 
backs of the hands. It is less frequent, however, and when 
it occurs is apt to be less extensive and less rebellious to 
treatment. 

Eczema of the palms and soles presents some peculiar 






ECZEMA. 117 

features. Owing to the thickness of the- epidermis in these 
localities, the appearance of the affection is somewhat marked. 
Infiltration, thickening, more or less callosity, dryness and 
Assuring mark the disease. It is very chronic and intractable. 
Sometimes deep and painful fissures occur, and when these 
are found upon the feet locomotion is rendered almost or 
quite impossible. The diagnosis of eczema of the palms and 
soles is often difficult. It is apt to be confounded with 
psoriasis and syphilis. From psoriasis eczema differs in 
showing, at times, moist and bloody fissures, while those of 
psoriasis are usually dry, and show little disposition to bleed. 
The patches of eczema are usually larger than those of psori- 
asis, and their edges pass gradually into the healthy skin. 
The patches of psoriasis are smaller, darker, covered with 
more abundant and paler or white scales. But the best point 
in diagnosis is the appearance of the disease on other parts 
of the body. When the palms and soles alone are affected, 
it is sometimes hardly possible to distinguish eczema from 
psoriasis. The latter, however, is exceedingly rare, so that 
the chances are one hundred to one in favor of any given 
case turning out to be eczema. The diagnosis between eczema 
and syphilis of the palms and soles is not usually so difficult, 
although sometimes, when the affection is not found else- 
where, one may be puzzled to come to a decision. The 
infiltration of syphilis is of a firmer nature than that of eczema; 
it also extends more deeply into the skin. The patches are 
smaller and more circumscribed, and sharply defined upon 
the edge, and they have a tendency to spread upon the 
periphery and to assume the circinate form. Eczema is 
usually much more uniformly diffused ; it is apt to be of a 
light color, while syphilis is darker, and sometimes ham- 
colored. It is also apt at times to itch, while syphilis does 
not itch. The history, and especially the occurrence of con- 
comitant lesions elsewhere, will often aid the diagnosis. 



118 DISEASES OF THE SKIN. 

The treatment of eczema upon the palms and soles must 
be of the most active and vigorous character, if relief is to 
be expected. The first point is to get rid of the thick epi- 
dermis. This may be accomplished by covering the palm 
with rags, spread with sapo viridis or wet with a five to ten 
grain solution of caustic potassa, and covered with rubber 
cloth. These are to be kept on day and night, until the 
epidermis is softened, macerated, and reduced to something 
like its normal thickness. Then stimulating ointments, con- 
taining mercury and tar, may be employed. When the phy- 
sician himself can conduct the treatment of the case, the 
following plan may be employed : Let the affected palm or 
sole be soaked for some minutes in water as hot as may con- 
veniently be borne ; and then, after the superfluous moisture 
has been hastily removed, let a twenty to forty per cent, 
solution of caustic potassa be firmly rubbed into the affected 
skin at all points, by means of a small mop, made of old- 
fashioned lamp-wick tied to a short stick. If this produces 
an uncomfortable heat, the surface may be washed with pure, 
cool water ; otherwise, the following ointment is to be applied 
directly : — 

]jc. Hydrarg. Ammoniat T)j 

Adipis gss 

Sevi Benzoinati 3V) - 9 J 

Ol. Amygdala? Dulcis TT\x 

Ung. Petrolii ad gvj. M. 

It should be spread over the surface, and also laid thickly 
upon rags and applied ; waxed paper being wrapped about each 
finger and placed over the palm, both for cleanliness sake and 
to aid the effect of the ointment. This is to be repeated daily 
until cracks heal up, the skin becomes thin and supple, and 
begins to assume a healthier appearance. Then the potassa 
applications are suspended, and a weak tar ointment — a drachm 
to the ounce— is rubbed in daily, to complete the cure. 



ECZEMA IN INFANTS. 119 

Though the treatment just described is more particularly 
applicable to the palms, yet it may also be employed upon 
the soles. However, a better treatment for that form of 
eczema affecting the thicker skin of the soles is the glycerole 
of lead treatment, described above. 

Eczema, when it occurs upon the nails, shows them de- 
prived of polish, rough, uneven, and often punctate or 
honeycombed. The nail becomes depressed, particularly 
about the root, at which point its proper nutrition is arrested. 
It may gradually recover its normal condition, or it may be 
cast off and replaced by a new nail. With regard to treat- 
ment, tar ointment, one drachm to the ounce, applied about 
the root, with the internal administration of arsenic, promise 
the best results. Treatment, however, not unfrequently seems 
to be entirely without effect. 

Eczema in Infants. Infants are liable to eczema from 
the first weeks of extra-uterine life, the chief differences be- 
tween the disease as shown in these cases and as it manifests 
itself in later life being, on the one hand, the restricted causes 
which may give rise to the disease, and on the other hand, 
the different appearance of the eruption, dependent upon the 
peculiar structure of the skin in early life. Eczema in infants 
and in young children is due either to digestive disturbances, 
to teething, or to that inherited weakness of constitution and 
poor nutrition generally attributed to the scrofulous habit. 
Bottle-fed infants are most apt to suffer from indigestion, and 
these are also most liable to. the eruption of eczema. While 
too much stress must not be laid upon the irritation of teeth- 
ing as giving rise to eczematous eruptions, yet when the 
tendency to eczema exists each tooth, as it comes out, will 
often be accompanied by an eczematous rash, which fades 
away as the tooth develops. It will be found, on observation, 
that the children of parents who suffer from a tendency to 
phthisis, or who present the symptoms commonly associated 



120 DISEASES OF THE SKIN. 

with the idea of scrofula, are most apt to be attacked with 
eczema, even when fed on the breast and presenting no signs 
of indigestion. When, as among the lower classes, improper 
nourishment and bad hygienic surroundings are added, the 
disease sometimes takes on a quite severe form. 

The diagnosis of infantile eczema is usually not difficult. 
It commonly occurs about the buttocks, genitalia and folds 
of the neck, in the form of E. erythematosum or E. inter- 
trigo. In the former locality it may be mistaken for syphilis, 
but the absence of deep infiltration, and, above all, the ab- 
sence of characteristic syphilitic lesions, whether of the palms 
and soles or of the body generally, will usually assist the 
diagnosis. The vesicular and pustular form is that commonly 
met with in infants, upon the cheeks, face and head generally. 
It sometimes runs on to E. rubrum, with very abundant dis- 
charge of serum. Occasionally shallow ulcers with crusts 
form, and in this variety it is at times difficult to say whether 
we have eczema or syphilis. Especially is this the case when 
the child is poorly nourished and emaciated. But in syphilis 
we are apt to have " snuffles," cracks in the commissure of 
the lips and lesions about the anus ; also, some of the lesions 
are apt to be infiltrated and to show deeper ulceration. Ec- 
zema, moreover, tends to itch to a marked degree, and this 
alone will commonly distinguish it. Papular eczema is more 
apt to occur in older children ; it may very readily be mis- 
taken for scabies, but the points given under that head (see 
Scabies) will serve to distinguish between the two affections. 

The treatment of eczema in infants must depend, to some 
extent, upon the cause. When indigestion seems to be at the 
bottom of it, the food must be changed and regulated. It is 
astonishing what blunders are made in the feeding of infants. 
The physician who desires to treat such cases of infantile 
eczema as come under his care with satisfaction and success, 
must study in each case to obtain suitable food and see that 



ECZEMA IN INFANTS. 121 

it is properly administered. Constipation in infants is a fre- 
quent cause of eczema, and should be combated. If habitual, 
the food should be changed with the view to improve this 
condition, while for occasional use the following powder may- 
be administered: — 

R. Hydrarg. Chlor. Mite gr. xij 

Pulv. Rhei gr. xviij 

Magnesias Calcinat 5 SS - M. 

Div in chart.- No. vj. 

Sig. — One every morning. 

This is the dose for an infant of eight to ten months ; the 
quantity, of course, should be regulated according to the 
general condition of the child, as well as its age. It should 
not be given for more than a few days, successively, and 
purging should be avoided. I find this a very useful powder 
in eczema of an acute or semi-acute character in constipated 
infants. If there is vomiting and dyspepsia, then lactopep- 
tine, or pepsin and bismuth, may be administered. 

When general debility exists, particularly when there is a 
scrofulous taint, syrup of the iodide of iron, in doses of five 
to ten drops, even in infants of a year old, may be adminis- 
tered. Sometimes, also, cod-liver oil, internally or by inunc- 
tion, may be employed. 

The external treatment of eczema in infants will depend 
upon the form of the disease present. When this is erythe- 
matous, and situated about the buttocks, genitalia, and folds 
of the neck, astringent dusting powders, as kaolin, oxide of 
zinc, and subnitrate of bismuth, may be employed ; while 
parts that are in apposition should be separated by a thin 
whisp of absorbent cotton. Starch powders often do more 
harm than good in these cases, because they soon get moist, 
caked, sour and irritating. Black wash and dilute lead water 
may be used in some cases. Ointments are generally not so 
convenient in this form of eczema. In vesicular and vesi- 
o 



122 DISEASES OF THE SKIN. 

culo-pustular eczema, and especially in eczema rubrum about 
the face and head, ointments are more useful. Scales and 
crusts should be cleaned away as far as possible, and then the 
milder and astringent ointments may be used first, and later 
those of a more stimulating quality. The following are con- 
venient formulae : — 

R. Pulvis Zinci Carbonat gj 

Ung. Cucumis ^j. M. 

R. Bismuthi Subnitrat ^j 

Ung. Aquae Rosae £]. M. 

In the more chronic forms of eczema rubrum of the face 
and scalp, more stimulating ointments are well borne, as 

this :— 

R. Picis Liquids gss 

Pulv. Zinci Oxidi 2[ss 

Ung. Aquae Rosae ^j. M. 

Instead of anointing with ointments, the cheeks and scalp, 
or other affected parts, may be painted with the following 
pigment, which is very effectual, and cannot be rubbed off 
like the ointments : — 

R. 01. Cadini gj 

Collodii 3j. M. 

Put a small camel' s-hair brush in the cork. 

The prognosis of infantile eczema is always favorable, and 
it is right to use every effort to cure the case. To postpone 
treatment and say, "oh, it will get well after teething," is, 
I think, unjustifiable and cruel. 

Eczema Marginatum. (See Tinea circinata.') 

Elastic Skin Man. (See Dermato lysis.) 

Elephantiasis (iv). Elephantiasis is a chronic hyper- 
trophic disease of the skin and subcutaneous connective 
tissue, characterized by enlargement and deformity of the 
part affected, accompanied by lymphangitis, swelling, oedema, 
thickening, induration, pigmentation and papillary growth. 



ELEPHANTIASIS. 123 

The affection usually begins by an attack like erysipelas, 
with lymphangitis, pain and fever, followed by slight enlarge- 
ment of the part. Similar attacks subsequently occur from 
time to time, the limb or region involved being slightly 
increased in size upon each occasion. At the end of a year 
or more, after a number of these attacks have taken place, 
the part is usually found to have increased considerably in 
size, to be chronically swollen, cedematous and hard. In 
the limbs, the leg particularly, not only will the entire mem- 
ber be found enlarged, but the skin itself decidedly hyper- 
trophied, as shown by the prominent papillae, fissures, and 
more or less discoloration and pigmentation. The process 
usually goes on until very considerable deformity results. 
The appearance of the disease varies in one part or another 
of the body. The commonest seat of disease is in the leg, 
one limb alone being generally attacked. The genitalia are 
next in point of frequency attacked. Other regions are more 
rarely assailed. 

The amount of pain attending the disease varies; it is 
sometimes severe during the inflammatory attacks, while at 
other times and in other cases no pain is felt. The increased 
weight of the part, as in the case of the scrotum or leg, may 
interfere with locomotion. 

Elephantiasis is found in all parts of the world, but is far 
commoner in tropical regions, where it seems to be endemic. 
Of late it has been supposed to be due to the presence of low 
animal organisms, known as \ filarice, in the blood and lym- 
phatics, giving rise to obstruction and inflammation in the 
latter. 

The treatment of elephantiasis may be medicinal or sur- 
gical. During an inflammatory attack, rest, with cold or hot 
applications and local sedatives are called for. After the pain 
and heat have subsided, inunction, with ung. hydrargyri or ung. 
hydrarg. ammoniat, may be practiced, and the limb, if that 



124 DISEASES OF THE SKIN. 

is the part attacked, is then to be encased in a closely fitting 
bandage, alone or in connection with other remedies. An 
excellent local application at this period is the earth bandage 
as employed by Hewson, of Philadelphia. This is essentially 
a scultetus bandage, on the strips of which has been spread 
a thin layer of kiln- dried clay earth, made into a thick paste 
with water. The strips having been carefully applied, a roller 
bandage is put on to keep them in place, and the limb kept 
immobile until the clay has dried. The gentle, uniform, but 
powerful contraction of the dessicating clay makes it one of 
the most satisfactory dressings which can be applied. A new 
bandage should be put on daily, and I can testify, from per- 
sonal observation, to the beneficial effects of this too-little- 
known plan of treatment. Some such treatment as this, with 
rest, is the most appropriate, and should be persevered in as 
long as it seems to do good. Internally, quinine may be 
given during the exacerbations, with a view of abating the 
fever. Iodide of potassium has also been recommended, but 
I doubt the efficacy of this remedy. Change of climate is 
sometimes of great importance. In cases where the disease 
has been contracted in a tropical climate, if the person seeks 
a more temperate region before the hypertrophic condition is 
far advanced, the attacks of fever often cease, and much may 
be hoped regarding recovery. On the other hand, if he re- 
mains in a tropical climate, repeated exacerbations of fever 
occur, each followed by a progressive advance in the hyper- 
trophic process, and recovery is almost impossible. Ligation 
of the femoral artery was formerly practiced in a number of 
cases of elephantiasis of the leg, but I believe this operation 
has been given up. When the scrotum is attacked, an opera- 
tion with the knife is the best treatment. 

The prognosis of elephantiasis, once fully developed, is 
unfavorable as regards entire cure. Much may be done, how- 
ever, in the earlier stages of the disease, to arrest its progress. 



EPITHELIOMA OF THE SKIN. 125 

Great deformity attends the disease, the " elephant leg" 
being a favorite and striking illustration in works on surgery. 
Elephantiasis rarely terminates fatally, though it is said a fatal 
result may follow an inflammatory attack in rare cases. 

Elephantiasis Grsecorum. (See Lepra?) 

Ephidrosis Cruenta. (See Purpura.') 

Epithelioma of the Skin (vi). Epithelial cancer of 
the skin may be either superficial, deep-seated, or papillary. 
The superficial or " flat" epithelial cancer usually makes its 
appearance as one or more grouped, small, yellowish or red- 
dish papules or elevations, having their seat in the upper 
layers of the skin. The disease may originate in a sebaceous 
gland, wart, or other growth, or in the form of a flat infil- 
tration. After a time, it may be months or even years, the 
tubercle, wart, or infiltration, as the case may be, becomes 
fissured or excoriated, a slight brownish crust forms upon it, 
under which is a scanty, watery, or viscid secretion. The 
course of the disease is slow, but gradually new lesions ap- 
pear, usually connected with the original one, and finally the 
tubercles break down, and ulceration of a superficial char- 
acter sets in. The ulcer, at first small, may spread until it 
attains the size of a coin, or even of the palm of the hand. 
The ulcer is characteristic. It is usually roundish, but may 
be quite irregular, with either sloping or sharply defined 
edges. The border may be smooth and on a level with the 
skin, but is usually elevated into a pearly ridge all around the 
ulcer. Its base is usually hard, and secretes a scanty, viscid 
fluid; it bleeds readily. There is usually a peculiar and 
characteristic picking or crawling sensation in the lesion 
when it first begins to become fissured or excoriated, but 
there is usually no pain unless the ulceration is considerable. 
When fully developed the ulcer may remain in statu quo for 
an indefinite period, the patient's health, meantime, being 
excellent ; or it may pass into the infiltrating, deep-seated 



126 DISEASES OF THE SKIN. 

variety, to be described. The lymphatic glands are not 
involved. 

Rodent ulcer is a form of this variety of epithelial cancer. 
Its most frequent seat is upon the eyelids, particularly near 
the inner canthus, and next to this upon the side of the 
nose. When fully developed it consists of a circumscribed, 
sharply defined, greater or less excavation, with a brownish- 
red or purplish-red, dry, or scantily secreting, mamillated 
surface, the ulcer having often a rolled border. Its course is 
very slow but relentless ; it invades every tissue with which 
it comes into contact, including muscles and bones. If 
neglected, great destruction of the parts may ensue, and 
even death from hemorrhage in very advanced cases. A 
peculiarity of this form of epithelioma is, that it is a disease 
of the upper part of the face, occurring usually above a line 
drawn across the face horizontally, on a level with the alse 
nasi and the lower border of the ears. 

Deep-seated variety. This variety of epithelioma, known 
also as the " infiltrating variety," is much more serious than 
the superficial variety of the disease. It begins as a split* 
pea-sized tubercle, situated in the skin and subcutaneous 
connective tissue. It sometimes, however, begins in a wart, 
like the superficial variety. It is reddish or purplish in color, 
surrounded by an areola, firm and hard to the touch, and 
accompanied by infiltration of the surrounding tissues. In a 
longer or shorter time, according to the malignancy of the 
case, usually months, ulceration usually begins, either from 
within or upon the surface, the tumor breaks down, and an 
ulcer of variable size results. This is deeply excavated, ir- 
regular in shape, with a violaceous base, secretes a viscid, 
offensive fluid, bleeds rapidly upon being touched, and is 
surrounded with infiltration, the skin being reddish in the 
neighborhood. The lymphatic glands become enlarged at a 
later period, the lancinating pains, which are often experi- 



EPITHELIOMA OF THE SKIN. 127 

enced from the beginning, become more severe, the patient 
suffers extremely and finally succumbs through marasmus and 
exhaustion. The course of this disease though sometimes 
slow, is occasionally rapid. Duhring alludes to a case where 
the disease ran its fatal course in a year. 

Papillary variety. In this variety of epithelioma, the lesion 
begins as a wart of split-pea size, or occasionally as a raised, 
lobulated, more markedly papillary formation of larger area. 
The surface is sometimes covered with dry, horny, epidermic 
scales, at other times it is moist and macerated. There are 
usually fissures secreting an offensive fluid, with sometimes 
cheesy, sebaceous matter. The fungous-looking' granulated 
surface sometimes develops into fleshy protuberances, and at 
other times spreads out more flatly. After a time it breaks 
down into a characteristic epitheliomatous ulcer, running the 
usual course. Occasionally the papillary growth proceeds 
from a pre-existing superficial or deep, infiltrated ulcer. 

Epithelioma is most commonly met with on the face, either 
on the lips or tongue, about the nose, the eyelids, the fore- 
head, the temples, or upon the scalp. The genitalia, espe- 
cially the penis and the scrotum in the male, and the labia 
in the female, are not uncommon seats of the disease. Epi- 
thelioma rarely occurs elsewhere, although it may be found 
in any part of the body. The lesion is usually single. 

The exciting causes of epithelioma are often obscure. 
Epithelioma of the lip or tongue often starts at a point 
where the mucous membrane has been irritated by a pipe- 
stem or a jagged tooth. Warts and naevi, both pigmentary 
and vascular, are structures in which it often originates. 
The disease is commoner among men than among women. 
It is much less malignant than any other form of cancer. 

The diagnosis of epithelioma is usually not difficult, ex- 
cepting in the earlier stages. It may be confounded with 
syphilitic tubercles and ulcerations, acuminated warts and 



128 DISEASES OF TH^ SKIN. 

lupus. The papule or ulcer of epithelial cancer, especially 
if about the genitalia, may also resemble chancre ; but the 
history of the case, the duration of the lesion, and a careful 
examination of its features, will aid in arriving at a correct 
opinion. The later syphilitic manifestations run a much 
more rapid course, and change in appearance more rapidly 
than epithelioma, and when ulcerative their secretion is much 
more abundant and purulent. Nevertheless, it is not rare, 
in my experience, to see cases of epithelioma about the face, 
which have been mistaken for the tubercular syphiloderm, 
and vica versa. What lends additional difficulty to the 
diagnosis in these cases is, that now and then the syphilitic 
lesion becomes transformed into epithelioma. I recall the 
case of a middle-aged woman showing a small ulcer near the 
inner canthus of the eye, which after some hesitation was pro- 
nounced syphilitic, and being treated with iodide of potassium 
healed up, returning again six months later, however, as 
unmistakable epithelioma, and quite uninfluenced at this time 
by the anti-syphilitic treatment. In making a diagnosis be- 
tween syphilis and epithelioma in any case, the points men- 
tioned should be borne in mind, and also the facts that the 
tubercular syphiloderm when ulcerating, usually shows several 
points of suppuration, while epithelial cancer is commonly 
single, and also that there is induration under and about the 
cancerous sore, while the syphilitic ulcer terminates abruptly 
against the sound skin. Finally, in cancer there is usually 
a picking and crawling sensation at first, and later lancinating 
pain. Syphilis is painless. 

Many epithelial cancers begin as warts, and it is often 
difficult to distinguish between a simple wart and a cancerous 
wart. Usually continued observation alone will decide. In 
elderly persons, any change in a wart of old standing upon 
the face, especially those flat, brown warts, not uncommon in 
advanced life, must be looked upon with suspicion. 



EPITHELIOMA OF THE SKIN. 129 

From lupus vulgaris, the diagnosis of epithelial cancer is 
chiefly to be made by the history. Lupus is a disease usually 
beginning in early life, and commonly has a long history. 
It is apt to be found in more parts of the body than one. 
When ulceration takes place, the diagnosis becomes more 
difficult, but a careful examination of the surrounding parts 
will commonly show some characteristic lupus lesions in the 
neighborhood. The discharge from a cancerous ulcer is 
usually pale, scanty and viscid, and is often offensive ; that 
from lupus is yellowish and puriform, and is not offensive. 

The treatment of epithelioma is external and local. The 
disease is to be removed as soon as the diagnosis is estab- 
lished. The knife, caustic, actual cautery or galvano-cautery 
may be employed, as seems most advisable in the particular 
case. Care must be taken to remove the entire growth, and 
even to go a short distance into the surrounding healthy 
tissues. Small and superficial epitheliomata are best removed 
by means of caustic applications, of which potassa fusa is 
the best. A stick of caustic potassa is to be wrapped in 
a rag, leaving only the point exposed, and this is passed over 
the growth, gently at first, to dissolve the horny epithelium, 
when this exists, and then the potash stick is to be bored into 
every part of the substance of the growth. While operating, 
the unhealthy tissues are found to give way very readily, so 
that it may easily be perceived, by the increased resistance 
offered, when the caustic reaches sound tissue. It must be 
remembered that the action of the potassa always proceeds 
a little farther after the caustic has been withdrawn. This 
must be borne in mind when operating in the neighborhood 
of important organs, as the eye, or where arterial branches 
may become involved. The application of the caustic potassa 
gives rise to severe pain, which, however, rapidly ceases after 
its withdrawal. When the effect has proceeded as far as is 
desirable, dilute acetic acid or weak vinegar, applied on rags, 



130 DISEASES OF THE SKIN. 

will neutralize the caustic influence, and put an immediate 
end to the pain. There is rarely any hemorrhage. The part 
operated on may be dressed with olive oil or some soothing 
ointment. The dressing is to be changed daily, and the 
eschar usually falls off at the end of a week or ten days, after 
which a rapidly granulating surface ensues, ending in an 
insignificant scar. 

Pyrogallic acid in an ointment of the strength of a drachm 
to the ounce, applied on cloths, from two to six days con- 
secutively, is a good remedy in certain cases, particularly 
when the patient cannot bear pain. It is usually painless. It 
may have to be re- applied, from time to time, the slough 
being cut or scraped away as it forms. Pyrogallic acid should 
not usually be trusted in the patient's hands, as too much 
action may be produced, or the effect may penetrate too 
deeply. 

Among other means of removing epithelioma the galvano- 
cautery, especially in operations near the eye, is recommended 
by those who have used it. Scraping with the dermal curette, 
or sharp spoon, alone, or followed by the actual cautery, is 
another mode of removal. For the use of the knife, which 
is not needed in the majority of superficial epitheliomata, if 
these are taken in time, reference may be made to the stand- 
ard works on surgery. 

The prognosis of epithelioma is unfavorable, excepting in 
the small and superficial lesions. Relapses are apt to take 
place after operation. 

Eruptions, Feigned, Factitious or Artificial. (See 
Feigned eruptions. ) 

Eruptions, Medicinal. (See Dermatitis medicamentosa?) 

Erythema (ii). Six varieties of erythema may be men- 
tioned : E. simplex, E. intertrigo, E. vaccinium, E. variolum, 
E. multiforme and E. nodosum. Of these the first four are 
simply hyperaemic, with little or no inflammatory exudation, 



ERYTHEMA. 131 

while the last two are characterized by more or less exudation 
of a plastic character, and are dissimilar enough to demand 
separate description. The erythemata disappear without 
leaving any mark or scar. 

Erythema simplex is characterized by redness, occurring in 
the form of variously-sized, diffused or circumscribed, non- 
elevated patches, irrespective of cause. There are two va- 
rieties : the idiopathic, under which head are included the 
erythemata occasioned by heat and cold, continued pressure 
or rubbing, and the action of irritant or poisonous substances, 
as mustard, arnica, various dye-stuffs, acids and alkalies; and 
the symptomatic, due to some general derangement of the 
economy, as disorders of the stomach and bowels, etc. Cer- 
tain general diseases are at times accompanied by hyperaemia 
of the skin, which shows itself in the form of roundish spots, 
the size of a pea or finger nail, to which the name roseola has 
sometimes been given. It denotes simply the form of ery- 
thema, and in no way indicates the nature of the disease which 
has brought it forth. 

The treatment of erythema must obviously depend upon its 
cause in any given case. The removal of the obvious cause 
is alone usually sufficient in idiopathic erythema, but in the 
symptomatic form of the disease the internal disorder to 
which the cutaneous manifestation is due must be diligently 
sought out and treated, with a view to removal. Locally, 
soothing and astringent lotions may be employed. A much- 
used lotion in erythema, when the skin is unbroken, is the 
following : — 

R. Acidi Hydrocyanici, dil ^j 

Bismuthi Subnitrat 3J-ij 

Aquae Aurantii Flor f^i y - M. 

Sig. — Outside use. 

The old "calamine" lotion, slightly modified, may also 
be used : — 



132 DISEASES OF THE SKIN. 

R. Pulv. Zinci Carbonat. Praecip., 
Pulv. Zinci Oxidi, 
Pulv. Amyli, 

Glycerinse aa £iv 

Aquas O ss. M. 

Dilute lead water, or lead water and laudanum, or simple 
alcohol and water, may be used with satisfaction in most 
cases. As for powders, though useful, they will be found in 
practice difficult to keep in contact with the skin. Oint- 
ments are very apt to disagree in simple erythema, and 
should, therefore, as a general thing, be eschewed. 

Erythema intertrigo is characterized by redness, heat and 
an abraded surface, with maceration of the epidermis. It 
occurs chiefly in those parts where the natural folds of the 
skin come in contact with one another, as about the nates, 
perineum, groins, axillae, and beneath the mammae, and is 
produced by the friction of two opposing surfaces. It is 
especially common among fat persons, women with pendulous 
mammae, and infants whose skin is tender. The skin feels 
chafed and becomes hot and sore. Perspiration also, at 
times, macerates the epidermis, and gives rise to the secretion 
of an acrid, mucoid fluid. If neglected, a true dermatitis 
may set in. The affection comes suddenly, and if taken in 
time may usually be quickly checked, but if not treated it 
soon becomes very annoying. Occurring between the nates, 
a common seat of the disease, it may interfere with walking. 
It is usually harder to cure in infants, where the diaper, satu- 
rated with more or less acrid secretions, is constantly in 
contact with the skin. 

The disease is one of summer rather than winter, although 
it may occur at any time of the year, if sufficient cause be 
present. It is sometimes brought on by wearing rough under- 
clothing. I have known severe erythema intertrigo of the 
nates and thighs caused by walking about, after sea-bathing, 



ERYTHEMA. 133 

in wet bathing clothes. The rough surface of the flannel, 
as it dries, becomes coated with minute acicular crystals of 
salt, which cut like tiny knives. The patient sometimes sup- 
poses himself to have been "poisoned" by a hired bathing 
dress, when the cause of his erythema is purely mechanical, 
as just mentioned. 

The treatment of erythema intertrigo is commonly an easy 
matter. As a rule, very little is required beyond cleanliness 
and attention. The parts should be washed with cold water 
alone, or with the sparing addition of castile soap, and dried 
with a soft rag or towel. The folds of the skin are to be 
separated and kept apart by pieces of soft linen, lint or ab- 
sorbent cotton. Dusting powders are the most convenient 
remedies in most mild cases. When there is little discharge, 
or none, starch or lycopodium may be used. Starch, however, 
is apt to cake and sour if dusted on a moist surface. The 
following powders are much less liable to this objection, and 
may be used alone or in combination : Oleate, oxide and 
carbonate of zinc, carbonate and subnitrate of bismuth, mag- 
nesia, fullers' earth, kaolin and talc. When starch is admis- 
sible, and there is no break in the skin, the following pre- 
paration is one of the best: — 

R. Pulv. Camphone ^iss 

Pulv. Zinci Oxidi, 

Pulv. Amyli aa ^j. M. 

To be made into a perfectly impalpable powder. 

The mixture should be kept in a tightly-corked, wide- 
mouthed bottle. 

In cases which are obstinate, diluted black wash, applied 
several times a day, alone or followed by the use of some 
bland powder, as above, is an efficacious remedy. Dilute 
alcoholic lotions, composed of alum or sulphate of zinc, a 
few grains to the ounce, also prove serviceable in stubborn 
cases. In intertrigo about the thighs and genitalia there is 



134 DISEASES OF THE SKIN. 

often an element of hyperidrosis. In these cases tincture of 
belladonna may be painted on the ,parts daily and followed 
by one of the more astringent powders, as the oxide of zinc. 
In the case of infants, when the intertrigo is about the anus, 
and the stools are thin, with an acid smell, the following 
powder may be given internally: — 

R. Calcis Praecipitat gr. iss 

Bismuthi Subnitrat gr. ij 

Sacch. Alb gr. iij. M. 

Sig. — One, thrice daily. 

When the stools show casein, minute doses of hydrochloric 
acid may be given. 

In addition to the common forms of erythema simplex and 
E. intertrigo, the following varieties are worthy of special 
mention. 

Erythema infantile, sometimes called " roseola infantile," 
is a not infrequent symptom of gastric disturbance in infants. 
It also results at times from the presence of worms, teething 
and various febrile complaints of infancy and childhood. It 
occurs chiefly on the trunk, both anteriorly and posteriorly, 
and to a less degree on the face and extremities. The lesions 
may be split-pea sized, discrete spots, or a diffuse punctate 
redness. It is usually very ephemeral. Erythema infantile 
may be mistaken for scarlet fever or measles, but the absence 
of high fever and of the characteristic symptoms of the latter 
affection, as they show themselves elsewhere than on the 
skin, will decide the question. 

Erythema vaccinium, sometimes called "roseola vaccinia," 
displays small or large, reddish, erythematous patches over 
the trunk and extremities. It occurs either on the first or 
second day after vaccination, or else at the period of begin- 
ning maturation of the vaccine vesicle, about the eighth or 
ninth day, rarely later. There is usually some fever. The 
eruption may be mistaken for the erythematous syphiloderm, 



ERYTHEMA MULTIFORME. 135 

and sometimes patients imagine that syphilis has been inocu- 
lated with the vaccine virus. It is important, therefore, to 
make the diagnosis. Of course, the history of syphilitic 
inoculation, with the double incubation period, etc., is con- 
clusive. The dusky red of erythema is also very different 
from the usual fawn color of the erythematous syphiloderm. 
(For an account of other eruptions following vaccination, 
see Vaccination eruptions.') 

Erythema variolosum, one of the prodromal rashes of small- 
pox, is important as an aid to the early diagnosis of the latter 
disease. It appears as a diffuse punctate redness, or in dis- 
crete, erythematous patches, often accompanied by small 
petechias. The characteristic locality of the eruption is over 
the abdomen and inner side of the thighs, also the flexor 
surface of the elbows and knees, the dorsal surfaces of hands 
and feet, the axillae and a triangular space over the sternum. 
It sometimes assumes the shape of long stripes over the tendon 
of the extensor longus of the dorsum of the foot. Rarely 
this form of erythema may attack the face and extremities. 
A later form of this variety of erythema may occur during 
the stage of suppuration and exsiccation. It may be local 
or may extend over the whole surface, and is apt to be 
accompanied by redness of the pharynx. 
Erythema Gangrenosum. (See Dermatitis Gangrenosa.') 
Erythema Multiforme (ii). This, which is a disease 
related, to a certain degree, with erythema simplex, and yet dif- 
fering from it, perhaps, chiefly, in the greater amount of exu- 
dation, is characterized by the occurrence of reddish, more or 
less variegated macules, papules and tubercles, occurring 
discretely or in patches of various size and shape. The name 
has been given to this form of erythema, on account of the 
protean character of the lesions which manifest themselves as 
erythematous patches of the most varied shapes and sizes, 
or as papules, vesico-papules and tubercles, scattered or in 



136 DISEASES OF THE SKIN. 

groups. Various names are given, denoting the arrangement 
of the lesions. Thus we have E. annulare, occurring in 
circular patches ; E. iris, occurring in concentric rings, 
often of beautifully variegated colors, as red, purple, yellow 
and blue. Sometimes the circles are very large, or are broken 
and assume gyrate forms; this is E. marginatum. Distinct 
papules and tubercles occur in E. papulatum and E. tubercu- 
losum. Erythema papulatum is the commonest variety. 
It shows itself in the form of isolated or aggregated flat 
papules of varied size and shape, bright red, bluish or 
purplish in color, and which soon fade, seldom lasting 
longer than a week or ten days. E. tuberculosum is simply 
an exaggeration of this form, and all of the varieties men- 
tioned are but forms and stages of the same process, and 
are often met with, two or more occurring together simulta- 
neously on the same individual. The lesions of E. multiforme 
disappear spontaneously, leaving, perhaps, slight pigmenta- 
tion and desquamation. 

Erythema multiforme is usually found on the backs of the 
hands and the fingers, forearms and legs occurring simulta- 
neously. It may show itself on the face and trunk. Some- 
times it attacks the mucous membranes. Now and then it is 
general, involving the whole surface. A marked feature of 
the disease is the disproportion between its appearance and 
the subjective symptoms to which it gives rise. Notwith- 
standing the angry look which the eruption often assumes, 
there is very little itching or burning. Sometimes constitu- 
tional symptoms, as malaise, headache, rheumatic pains, and 
gastric derangement, are present in marked cases. 

The affection is much commoner in the spring and fall, 
although it sometimes occurs at other periods of the year. 
It is among the eruptions of the skin more frequently met 
with in this country. The statistics of the American Dermato- 
logical Association show 683 cases of erythema multiforme 



ERYTHEMA NODOSUM. 137 

among nearly 59,000 cases of skin diseases reported — a pro- 
portion of 1. 16 per cent. 

The papular form of erythema multiforme is sometimes 
brought on by derangement of the stomach, and runs a 
course resembling that of urticaria. Genito-urinary diseases 
are said to dispose toward the occurrence of the efflorescence. 
In the majority of cases no active treatment is called for; 
light diet, the avoidance of stimulating drinks, mild saline 
laxatives, with the local application of dilute alcohol, or of 
carbolic acid, may be employed, as this : — 

R. Acidi Carbolici 3J 

Glycerinae f % j 

Aquae Oj. M. 

Dusting powders, as that of camphor, oxide of zinc and 
starch, given under erythema intertrigo, also prove useful at 
times. 

Erythema Nodosum (ii). This affection is character- 
ized by the formation of rounded or ovalish, variously-sized, 
more or less elevated, reddish nodes. The disease is apt to 
be ushered in with some disturbance of the system ; the 
nodes often appear suddenly ; they may come on any part 
of the body, but are commonly found on the legs and arms. 
They vary in size from a small nut to an egg, are reddish in 
color, tending to become bluish or purplish. As they dis- 
appear, they undergo various changes of color, like a bruise, 
and it is often difficult to distinguish the lesions from ordi- 
nary contusions, especially when they occur over the shins. 
When the disease is at its height, the lesions have a tense, 
shining look, as if they contained fluid, and often an indis- 
tinct sense of fluctuation is perceptible. They never sup- 
purate, however. Not unfrequently they are more or less 
hemorrhagic in character. They vary in number from a few 
to a dozen or more. They come out, as a rule, in crops. 
They are painful or tender on pressure, and are usually 
10 



138 DISEASES OF THE SKIN. 

attended by burning sensations. Sometimes the lymphatic 
vessels are involved. The affection usually terminates in 
recovery in two to four weeks. An "ominous ' ' form has been 
described by authors, which is said to be the precursor of tuber- 
culosis. I myself saw one case, in which a little boy, after 
suffering for three or four weeks with erythema nodosum, fell 
into a delirious condition and died, with the symptoms of 
tubercular meningitis. 

Erythema nodosum is a rare disease. The statistics of the 
American Dermatological Association show that it occurred 
only twenty-seven times in 16,863 cases of skin disease. 

No active treatment is called for. Rest in the recumbent 
posture, the correction of any functional derangement ; qui- 
nine, if required, is all that will usually be needed. If there 
is a family history of tuberculosis, it will be better to give 
cod-liver oil from the beginning. 

Excoriations, Neurotic. (See Neurotic Excoriations.*) 

Exfoliative Dermatitis. (See Dermatitis Exfoliativa.) 

Farcy. (See Glanders.) 

Favus. (See Tinea favosa.) 

Feigned Eruptions. Eruptions, self-produced, with or 
without the intention to deceive, are probably of more fre- 
quent occurrence than would be supposed, from the rarity 
with which such cases are found reported in medical journals. 
Such cases are commonly found among hysterical women, 
or among soldiers, sailors and prisoners, who are apt to be 
malingerers. Sometimes they assume the form of erythema, 
or urticaria, circumscribed dermatitis, pemphigus, or other 
bullar eruptions, and occasionally, even ulcers and gangrene 
have been produced. In rare cases, ecchymoses, whitlow, 
alopecia, sooty sweat, or the appearance of minute insects, 
have been brought about artificially. Two points must be 
remembered in such cases. First, the disease is almost al- 
ways anomalous in the time, place, or manner, of its appear- 



FISSURES. 139 

ance, and in the course it runs. Second, it almost always 
shows some sign of having been artificially produced, and is 
almost invariably in a position easily and conveniently ac- 
cessible to manipulation. Thus the face, forearms, chest and 
mammary region, and after these the lower limbs, are most 
apt to be the seat of the eruption. . If, in addition, any 
motive for malingering, or for exciting interest and sym- 
pathy, can suggest itself, the case should be very carefully 
looked into from this point of view. The lesions and their 
neighborhood should be examined, with a view to detecting 
any trace of the use of mechanical irritants, or of such 
domestic articles as are apt to be used ; mustard, vinegar, 
cantharides, nitric acid, etc., have all been employed. The 
examination should always be so made as to avoid suspicion 
of its object, and if the physician comes to a positive con- 
clusion that the eruption, in any given case, has been arti- 
ficially produced, let him not think of proclaiming his con- 
clusion, which will probably only lead to the suspicion, on 
the part of friends and relatives, that he does not know his 
business. Better to treat such cases with placeboes, and have 
them recover spontaneously, without forcing the patient to 
admit a deception, or pitting one's reputation for sagacity 
against the patient's veracity. Of course, I have chiefly in 
mind the case of women feigning skin diseases. 

Fibroma Molluscum. (See Molluscum fibrosum.) 
Filaria Medinensis. (See Guinea worm.) 
Filaria Sanguinis Hominis. A parasite found in the 
blood vessels and lymphatics, and thought to be largely con- 
cerned in the causation of elephantiasis, at least in eastern 
countries. (See Elephantiasis.) 

Fish-skin Disease. (See Ichthyosis.) 
Fissures in the skin are generally due to eczema. (See 
Eczema.) They usually occur in places where the skin is 
rendered unusually brittle by inflammation, and at the same 



140 DISEASES OF THE SKIN. 

time is subject to flexure. The ends (pulp) of the fingers 
and flexures of the fingers and toes are common seats of 
fissures. Also the muco-cutaneous juncture of the mouth and 
anus, and the posterior part of the ear where it joins the scalp. 
The treatment of fissures is usually at first stimulant, and 
then protective. Chaps and fissures about the lips and anus 
should be slightly torn open, and then touched with a point 
of solid nitrate of silver or a sharpened match smeared with 
a strong red oxide of mercury ointment, 40 to 60 grains to 
the drachm. Ointments containing tar are also useful, as 
described under eczema of the anus. Fissures behind the ears 
may be treated in the same manner, with a slightly milder 
degree of stimulation. Fissures occurring in the ends of the 
fingers may be treated by soaking in hot water, to soften the 
thick epidermis, and then rubbing in a ten per cent, solution 
of oleate of mercury, or, if painful, with equal parts of the 
ten per cent, oleate of mercury and oleate of morphia. If 
the cracks are deep, they may be touched with the solid 
nitrate of silver stick, after preliminary soaking in hot water, 
and may then be painted with a solution of gutta percha for 
protection. Or the soaked finger ends may be rubbed with 
a 5-15 grain solution of caustic potassa, and then kept con- 
stantly wrapped in unguentum diachyli. I mention these 
various remedies, because what will suit one case will do no 
good in another. Each must be tried in turn ; much perse- 
verance must be exercised, and, at best, a very guarded 
prognosis must be given in fissures of the finger ends. In 
some cases they seem, like dryness and brittleness of the hair 
and splitting of the nails, to be rather the expression of a 
constitutional peculiarity than a disease. 

Frambcesia (vi), called also yaws, pian, and endemic 
verrugas, is an endemic disease characterized by general and 
cutaneous symptoms, occurring in the West Indies and other 
tropical countries. The eruption consists of variously-sized 



FURUNCLE. 141 

papules, tubercles and tumors, of a reddish or yellowish color. 
The lesion appears as a yellowish or whitish point or spot, 
which gradually enlarges and projects from the surface, look- 
ing, when fully developed, like a piece of cotton wick, a 
quarter of an inch or less in diameter, dipped into a dirty 
yellow fluid, and stuck on to the skin, in a dirty, scabby, 
brownish setting, and projecting to a greater or less extent. 
Or at times the lesions look like red currants, with flat tops, 
of a bright pink color, glassy, semi-transparent. Larger 
lesions look like cherries. The tubercles may be smooth, 
scaly or ulcerated. The eruption generally manifests itself 
on the face, upper or lower extremities and genitalia. The 
largest growths occur on the lips, eyelids, toes and genital 
organs. The lesions are not painful or itchy. The disease 
is probably not hereditary. Most observers consider it con- 
tagious. It bears no relation to syphilis. The treatment 
which is effective consists of hygiene, good food and tonics, 
with cleanliness and the use of carbolic acid solution, or a 
weak nitrate of mercury ointment locally. 

Freckle. (See Lentigo.) 

Furuncle (ii), commonly known as boil, is a deep-seated, 
inflammatory disease, characterized by one or more variously- 
sized, circumscribed, more or less acuminated, firm, painful 
formations, usually terminating in central suppuration. Boils 
may occur singly, or oftener in numbers. When they occur 
in successive crops the condition is known as furunculosis. 
The lesion, at first a small, ill-defined, reddish spot, situated 
in the true skin, and tender and painful from the first, soon 
becomes larger, slightly elevated, and shows a tendency to 
suppurate about its centre. It arrives at maturity in a week 
or ten days, and is then a slightly-raised, rounded or pointed 
formation, with a suppurating centre, called the core. At 
times no centre of suppuration forms ; it is then called a 
" blind boil." The size of a boil may vary from that of a 



142 DISEASES OF THE SKIN. 

split pea to a large coin. Its color is dusky red ; it usually 
gives rise to a dull, throbbing pain, increasing in intensity 
until suppuration takes place, and then subsiding. Boils are 
exquisitely tender ; the least touch causes pain. 

Though the boil may attack any part of the body, its 
favorite seats are the face, ears, neck, back, axillae, buttocks, 
perineum, scrotum, labia and legs. Sometimes it is accom- 
panied by some general constitutional disturbance. Neigh- 
boring glands may be sympathetically enlarged. 

Boils sometimes occur as complications or sequelae of other 
diseases, e. g. eczema. An acute attack of eczema often winds 
up with a crop of boils. Sometimes the boil tends to return 
again and again in about the same spot. 

The causes giving rise to boils are various and sometimes 
obscure. Often they are the result of a low and depraved 
condition of the system. General debility, overwork of a 
mental sort, excessive bodily fatigue, nervous depression, im- 
proper food and irregularity of the functions of the body are 
among the common causes of boils. They are sometimes 
encountered, however, in persons apparently enjoying perfect 
health, and given to active and varied out-door exercise 
and amusement. The boils to which the hydropathist points 
with pride, as evidence that the peccant humors are being 
"driven out," are in reality the evil result of erroneous 
hygiene and regimen. Boils not unfrequently occur in the 
course of other diseases, as diabetes, chlorosis, fevers, uraemia 
and septic pyaemia. Occasionally certain atmospheric con- 
ditions, prevailing chiefly in the spring and autumn, seem 
influential in determining the occurrence of boils, which at 
times appear to prevail as a sort of epidemic. 

The diagnosis of furuncle is generally easy, the affection 
being familiar to every one. From anthrax, or carbuncle, it 
differs in only having one point of suppuration — the core — 
while the former has several or many such centres. The 



FURUNCLE. 143 

furuncle also is inclined to be rounded or acuminate ; car- 
buncle is flat. Furuncle is small ; carbuncle varies in size, 
from half an inch to three or four or more inches in diameter; 
furuncle is tender to the touch; carbuncle, though spon- 
taneously painful, is not tender. Boils generally occur in 
numbers ; carbuncle is commonly single. Now and then 
certain pustular syphilodermata resemble boils, but their 
indolence, painlessness and darker, duskier color, together 
with the chronic slow course which they run when un- 
affected by treatment, will rarely permit difficulty in the 
diagnosis. 

The successful treatment of boils is, at times, by no means 
easy. Each case demands careful study, with the view, if 
possible, of ascertaining the cause at work, and obviating this, 
if it can be done. The various functions of the body are to be 
carefully regulated. The diet should be of good quality and 
varied. Wine and malt liquors may be prescribed in rare 
cases, and when the patient is not accustomed to their use. 
The regimen should be moderate and conducive to the gen- 
eral improvement of the system. Fresh air and out-door 
exercise are to be urged in most cases. Tonics are very often 
called for. Quinine in considerable doses, as much as sixteen 
grains per diem, and iron, alone or with strychnia, may be 
given. Cod-liver oil is also suitable in some cases. The 
mistura ferri acida, so often prescribed in eczema, etc., is 
useful at times: — 

R. Magnesii Sulphat ^j 

Ferri Sulphat gr. iv 

Sodii Chloridi ^ss 

Acidi Sulphurici dil f^ij 

Infus. Quassue ad f^>i v « M. 

Sig. — Tablespoonful in a tumblerful of water, before breakfast. 

Arsenic, alone or in combination with iron, is sometimes 
useful. The following is a convenient formula: — 



144 DISEASES OF THE SKIN. 

R. Liquor Potassae Arsenitis f^ij 

Vini Ferri ad ,.... f^iv. M. 

SiG. — Teaspoonful, three times a day, after meals. 

Other remedies are : the sulphite or hyposulphite of sodium, 
in fifteen to thirty-grain doses, every two or three hours ; sul- 
phide of calcium, in doses of one-eighth to one-quarter of a 
grain every two hours ; liquor potassse, in ten to twenty minim 
doses, with a bitter infusion, as calumba or quassia ; fresh 
yeast, in tablespoonful doses, three times daily ; syrup of the 
hypophosphites of lime, iron, soda and potassa ; tar water, 
up to a quart daily, and phosphorus. Such are the remedies 
most usually relied upon in the treatment of furunculosis. No 
one can be recommended as a specific ; what will do good in 
one case may fail in another. 

Locally, one method of aborting the forming boil may be 
recommended ; it is when a hair is growing out of the centre 
of the boil to pull it out. This will sometimes check the further 
development of the boil. The application of cold, in the form 
of powdered-ice poultices, is recommended by Hebra. The 
use of caustics, as a red-hot needle, nitrate of silver, or a 
mixture of equal parts carbolic acid and glycerine, nitric 
acid, or acid nitrate of mercury, may be used to the apex of 
the forming boil. Wilson recommends, when the areola is 
forming, the application of a galbanum plaster with opium, 
spread on chamois skin. It is said that under this applica- 
tion the pain ceases, and the separation of the core takes 
place painlessly. When the boil begins to discharge, a hole 
is cut in the plaster, to permit the escape of the products 
of suppuration. When the areola is of considerable size, 
a starch poultice may be applied, or a linseed poultice 
smeared with resin cerate, or when there is much pain, 
made with lead water. Incisions should not be employed 
at any stage. 

Gangrene of the Skin. (See Dermatitis gangrenosa.*) 



GUINEA-WORM DISEASE. 145 

Glanders (ii), called also Farcy and Equinia. A malig- 
nant, contagious disease, derived from the horse, and mani- 
festing itself, after a period of incubation, by grave con- 
stitutional symptoms, with inflammation of the nasal and 
respiratory passages, and a deep-seated pustular, vegetating, 
tubercular ("farcy buds"), or hemorrhagic, ulcerative form 
of eruption. The disease is rare and frequently fatal. 

The local treatment of glanders involves destruction of the 
virus by some cauterizing agent applied to each ulcer. Nitric 
acid, carbolic acid, and chlorine water, are to be preferred. 
As the abscesses form they should be opened and kept con- 
stantly cleansed by injections of permanganate of potassium 
solution and by carbolic acid. Ulcers of the nostrils are to 
be touched and washed with carbolic acid solution, and 
touched with tincture of iodine or solution of nitrate of 
silver. Internally, arsenic, nux vomica, carbolic acid, and 
especially iodide of potassium, are recommended, in addi- 
tion to which, the general symptoms arising in each case are 
to be vigorously combated. 

Glossy Skin. (See Atrophy of the skin.) 

Graying of the Hair. (See Canities.) 

Grocer's Itch. Eczema of the hands and arms, due to 
the irritation produced by handling sugar. 

Guinea- worm Disease (ix). An affection chiefly of tropi- 
cal countries, caused by a parasite known as the "Guinea- 
worm," Dracunculus, or Filaria Medinensis. It is particu- 
larly common along the west coast of Africa, in Senegal and 
Guinea, and in Egypt, Persia and India. I think it has also 
been met with in the southern United States and the West 
Indies. It attacks the skin, giving rise to marked inflamma- 
tion, which manifests itself in the form of a species of boil 
or painful tumor. The full-grown worm is from J ¥ to J^ inch 
in thickness, and varies from several inches to three feet in 
length, according to its age. The young worm, when of 



146 DISEASES OF THE SKIN. 

microscopic size, finds its way by boring into the skin and 
deeper tissues, and there takes up its habitat, growing gradu- 
ally, for months, without attracting attention, until it attains 
a sufficient size to excite irritation and inflammation. Sooner 
or later a boil or tumor forms and breaks, showing the pres- 
ence of the worm. Only one worm is present in each tumor, 
although a number of tumors may exist simultaneously. The 
disease is usually contracted in low, swampy places, by per- 
sons who go barefoot, and usually attacks the feet and lower 
extremities. The treatment consists in extracting the worm, 
inch by inch, and day by day, as soon as it makes its appear- 
ance on the surface, being careful not to break the creature 
during the operation. The internal administration of asa- 
foetida, in one case with poulticing, appeared to draw out the 
worm, which was found entire in the poultice. Galvanism 
has also recently been applied with great success, one pole 
of a battery being placed on the head of the worm, and the 
other held by the patient. 

Gumma. (See Syphiloderma.) 

Haematidrosis. (See Purpura.') 

Hair, Diseases of the. (See Atrophy of the hair, Hir- 
suties, Alopecia, Canities.') 

Heat, Prickly. (See Miliaria.) 

Hemiatrophia facialis. (See Morphcea.) 

Hereditary Syphilis, Skin Affections in. (SeeSyphi- 
loderi7ia.) 

Herpes. Herpes is an acute inflammatory affection, con- 
sisting of one or several groups of vesicles, occurring, for the 
most part, about the face and genitalia. Ordinarily, it occurs 
without any accompanying general symptoms, but sometimes 
there is concomitant slight malaise and feverishness. It is 
often symptomatic, occurring in the course of a common 
cold or of digestive disorders, or in pneumonia, pleurisy, 
remittent and other fevers, etc. The lesions are commonly 



HERPES. 147 

clustered, three or four together, of the size of a pin head to 
that of a small split pea, containing clear serum or sero-pus, 
situated on a somewhat inflamed base, and becoming quickly 
dried and covered with a yellowish crust. There is usually 
a certain feeling of tension and burning, with some itching. 
The affection runs an acute course, lasting a week or ten 
days. There are two regions, the face and genitalia, on 
which herpes is usually found, and from which the two varie- 
ties take their name. 

Herpes facialis is ordinarily seen in the form of the well- 
known "fever blister." It occurs on the lips, alse of the 
nose, and more rarely elsewhere on the face and about the 
ears. Herpes is also found on the mucous membrane of the 
oral cavity, forming those little, shallow, punched-out ulcers, 
called "cankers." On the tonsils, where herpes is occasion- 
ally found, it is apt to be mistaken for diphtheria, especially 
if extensive and accompanied by enlargement of the tonsils 
and by febrile reaction. Sometimes this form attacks several 
members of the same family simultaneously. The character- 
istic, discrete, punched-out ulcers, resulting from an early 
rupture of the vesicles, serve to establish the diagnosis. 
Herpes of the inside of the lips and of the tongue may be 
mistaken for mucous patches, but the latter are larger, flatter 
about the edge, and somewhat irregular in outline, gray in 
color, and with a reddish or violaceous edge. Herpes, on 
the other hand, is smaller, the lesions circular, or made up 
of intersecting circles, the edges sharply defined and punched 
out, and the color almost invariably yellowish. 

Herpes progenitalis is found on both males and females. 
The vesicles are usually four to six in number, varying in size 
from that of a pin's head to that of a split pea. They occur 
usually close together and are apt to coalesce. The whole 
area covered by the group of lesions is not greater than that 
of a quarter-dollar. The parts usually affected are, in the 



148 DISEASES OF THE SKIN. 

male, the preputial sulcus, the lining of the prepuce, the 
glans, the margin of the prepuce and, more rarely, the shaft 
of the penis. In women, herpes progenitalis is very uncom- 
mon, excepting among prostitutes. The lesions are found 
upon the labia minora, prepuce of the clitoris, labia majora, 
clitoris, introitus vaginae and, more rarely, on other neigh- 
boring parts. The attention of the patient is called by slight 
itching and burning; a small, red patch is observed, on which 
a crop of vesicles, at first clear, but soon becoming purulent, 
is observed. If situated on the mucous membrane the vesicle 
soon breaks down, so that the lesion which is, in fact, first 
noticed is a superficial erosion. Unless irritated, the lesions 
tend to heal within a week or two. The tendency to relapse 
is very marked. In the female it may recur with each cata- 
menial period, while in the male each coitus may be followed 
by an outbreak. Venereal diseases of a non-Syphilitic char- 
acter, as gonorrhoea and balanitis, seem to predispose to the 
occurrence of the affection. It is confined, in the male, to the 
periods of youth and early manhood, but in the female may 
occur as late as middle age. Herpes progenitalis is apt to be 
mistaken for chancroid. In the earlier stages, indeed, the 
lesions are identical in appearance in both diseases. The 
number and distribution of the lesions is a great help. The 
lesions of chancroid are not so numerous as those of herpes, 
and are not grouped together in the way the latter are. When 
multiple the lesions of chancroid are the result of auto- 
inoculation, and are, therefore, of different ages. Time, also, 
shows the difference. After a few days the herpetic sore 
begins to get better, while the chancroid is getting worse. 
The syphilitic initial lesion need not often be confounded 
with the herpetic vesicle. It does not begin as a pustule; it 
is seldom multiple ; it is indurated at some time in its course; 
is accompanied by indurated glands, and does not appear as 
a sore until some days after the exposure. In the female the 






HERPES GESTATIONIS. 149 

later syphilitic lesions may sometimes be mistaken for herpes, 
and vice versa. The same principles of diagnosis which come 
into use in distinguishing herpes from the other affections 
above mentioned will, however, be found of service in such 
cases, and in any case careful observation of the lesions for 
several days will much assist the conclusion. Eczema of the 
genitalia may resemble herpes, but the itching and generally 
severe and more extensive character of the eczematous disease 
serves to distinguish it. 

The treatment of herpes facialis is very simple, a soothing 
ointment being usually all that is required. Now and then, 
when the disease is extensive and spreads over the face with 
violently inflammatory symptoms, as occurs in rare cases, a 
poultice of bread crumb and cold, dilute lead water, or 
fomentations with lead water and laudanum, may be required 
for twenty-four or forty-eight hours, after which an ointment 
of a drachm of subnitrate of bismuth to the ounce of cold 
cream may be employed as the lesions dry up and crust. 
Herpes progenitalis usually requires very little treatment. 
Sometimes, however, various remedies are required. The 
best remedy for ordinary use is dilute lead water, applied on 
a soft piece of linen or a whisp of absorbent cotton. Black 
wash is a good dressing in many cases ; or finely-powdered 
nitrate of bismuth may be used. Sometimes more stimulating 
applications are required. Powdered calomel, sprinkled on 
the erosions morning and night, or equal parts of calomel 
and oxide of zinc may be used. When the disease is prone 
to recur, astringent washes may be employed as a prophylactic. 
Circumcision is sometimes useful in inveterate cases occurring 
in the male, but even this has been known to fail. 

Herpes Circinatus. (See Herpes iris and Tinea cir- 
cinafa.) 

Herpes Gestationis (ii). A rare affection of the skin 
peculiar to pregnancy. It consists in the development of ery- 



150 DISEASES OF THE SKIN. 

thema, papules, vesicles and bullae, vesicles predominating. 
They are attended with intense itching and burning sensa- 
tions. They are commonly grouped, but do not follow any 
nerve tracts. The vesicles and bullae vary in size ; they may 
be pea-sized or as large as a walnut. The lesions usually first 
appear on the extremities, and afterward involve other por- 
tions of the body. It is an affection directly dependent 
upon the gravid state of the uterus. It may appear at any 
period of gestation, up to the seventh month, and, when 
present, usually continues until after delivery. It does not 
terminate its course immediately after delivery, but slowly 
retrogrades by the development of fewer and fewer vesicles ; 
it is apt to recur with succeeding pregnancies. It is at times 
accompanied by urticaria, neuralgia and other neurotic affec- 
tions. It appears to be a form of Dermatitis herpetiformis 
(Duhring). 

Herpes Iris (ii) is an acute, inflammatory disease, charac- 
terized by one or more groups of variously-sized vesico-papules 
or vesicles, arranged in the form of concentric rings, attended, 
as a rule, by the display of varied colors. The patches vary 
in size from a small coin to several inches in diameter, and 
are made up of a number of usually rather indistinct vesico- 
papules or vesicles, which arrange themselves side by side, so 
as to form a perfect ring. It is a peculiarity of the disease, 
that new vesicles are constantly forming on the periphery 
while the centre is healing up. When there are a number of 
independent patches they sometimes coalesce, and the inter- 
stices of the concentric and variegated circles present a pic- 
ture so striking that once seen it can never be forgotten. It 
looks, sometimes, as if the patient had been tattooed in rings 
of various colors, the prevailing tints being red, yellow and 
brown. The backs of the hands and feet, and the arms and 
legs, are the localities usually attacked, but sometimes the 
trunk is also involved. The eruption is almost entirely un- 



HERPES ZOSTER. 151 

accompanied by sensation of any kind. It tends to recur. 
It is a rare disorder, and is more apt to occur in the Spring 
and Autumn. 

The disease is closely related to Erythema multiforme, de- 
scribed above. 

Treatment is of but little avail, as a general thing. Large 
doses of quinine, given early in the attack, seem in some 
cases to have the effect of arresting the disease. The vesicles 
should be protected, or, if broken, soothing lotions or oint- 
ments, as in the treatment of acute eczema, may be em- 
ployed. 

Herpes Tonsurans. (See Tinea tonsurans.} 

Herpes Zoster (ii) is an acute inflammatory disease, char- 
acterized by groups of vesicles, situated upon inflamed bases, 
usually accompanied by more or less neuralgic pain. The 
pain usually precedes the eruption, sometimes by several days. 
It is apt to be disproportionate to the amount of eruption. 
Occasionally it is entirely absent. The eruption makes its 
appearance in the form usually of an inflamed condition of 
the skin, attended with heat and burning sensations, and 
groups of discrete pin-head to split-pea sized vesicles, situated 
on a bright red surface, appear over the region. The vesicles 
are often crowded together so as to coalesce, forming irregular 
patches. New vesicles continue to appear until the fourth to 
the eighth day, when the eruption is at its height ; it remains 
in this way a few days, and then begins to decrease, the vesi- 
cles shriveling, and by the tenth day or so leaving brown 
crusts, which drop off. The vesicles do not burst, as do those 
of eczema. Ten days to three weeks is the average duration 
of an attack. The eruption does not always run a typical 
course. Only a few vesicles may appear, or they may abort 
before fully developing. On the other hand they may sup- 
purate and leave scars, though the disease commonly leaves 
no trace. The neuralgia varies from a very slight tingling to 



152 DISEASES OF THE SKIN. 

m 

the most excruciating pain. Herpes zoster may attack any 
part of the body, but is commonly found upon the trunk and 
head ; less frequently upon the limbs. It follows very closely 
the course of the nerves, and the eruption is named according 
to the region upon which it occurs, as Zoster capitis, Zoster 
brachialis, Zoster facialis, etc. On the head it most fre- 
quently occurs in the course of the supra-orbital nerve, and 
it may affect the eye, giving rise to severe pain. On the head, 
both sides are sometimes affected ; elsewhere the affection is 
almost always unilateral, so as to give rise to a popular super- 
stition, that if the ' 'shingles" (occurring on the trunk) should 
go all the way round the body the patient would certainly 
die. The chest is the commonest seat for the occurrence of 
the eruption ; and the names formerly given to the disease, 
zona, cingulum, a girdle, indicate this. Involving the inter- 
costal nerves, the neuralgia often causes the affection to be 
taken for pleurisy, until the eruption makes its appearance. 
When it occurs on the limbs the flexor surface is commonly 
attacked. It rarely occurs below the knee. The course of 
herpes zoster is acute, and though somewhat variable as to 
duration, it tends to recovery. 

Herpes zoster rarely occurs twice in the same person. 
Now and then, however, cases are met with where it recurs 
year after year, perhaps six to nine times. Its etiology is 
obscure, but it is well recognized that the disease is depend- 
ent upon a peculiarly irritable or inflamed condition of the 
cutaneous nerve trunks and branches. Practically, the dis- 
ease consists in an inflammation of the spinal ganglia, the 
influence of which is carried forward, along the nerves, to 
their termination upon the skin. 

The diagnosis of well-developed typical herpes zoster pre- 
sents no difficulty. The neuralgic pain, the appearance of 
the vesicles in distinct groups, upon a highly inflammatory 
base, and the tendency to preserve their form intact, are 



HERPES ZOSTER. 153 

characteristic. In eczema, which it most resembles, the lesions 
tend to exude moisture, dry and crust, while in herpes zoster 
there is no discharge. Eczema itches, H. zoster burns. 
From simple herpes, H. zoster is distinguished by the pres- 
ence of pain, by its non-recurrence, its unilateral character, 
and by its rare occurrence upon the favorite seats of herpes, 
the lips, alae of the nose, and genitalia. 

The treatment of herpes zoster is largely palliative. The 
disease runs a naturally favorable course, tending to recovery, 
and the symptoms of neuralgia and burning in the seat of 
eruption alone require treatment. For the neuralgia, I know 
of no remedy more efficient than the phosphide of zinc, in 
doses of one-third of a grain, given at the commencement 
of an attack, and repeated every three hours. It may be 
combined with one-sixth of a grain of extract of nux vomica. 
If this fails in severe neuralgic cases, morphia may be given 
at night. Electricity, in the form of the constant galvanic 
current, often gives relief. Five to ten cells may be used, 
the sponge electrodes being placed along the course of the 
nerves, and directly to the seat of the eruption. The appli- 
cation should be made once, or if possible, twice a day, for 
fifteen minutes at a sitting. This application also relieves 
the after pains of herpes zoster, when these supervene on the 
eruptive stage. Among local applications, powders are only 
available when, by any chance, the vesicles have become 
ruptured. In other cases, lotions, ointments, or pigments, 
are more convenient. The following is a convenient pow- 
der : — 

R . Pulv. Amyli, 

Pulv. Zinci Oxidi aa % ss 

Pulv. Morphiae Sulphat gr. ij. M. 

It is a good plan to sew a soft flannel bandage around the 
affected part, after the application of this powder, to be re- 
moved only when required. This will prevent the rubbing 



154 DISEASES OF THE SKIN. 

of the clothing, which is very irritating. Among lotions, 
lead water, lead water and laudanum, fluid extract of grin- 
delia robusta, half an ounce to the pint of water, or the 
following zinc lotion : — 

R. Zinci Carbonat. Praecip., 

Pulv. Zinci Oxidi, 

Pulv. Amyli, 

Glycerinae aa % iv 

Aquae Oss. M. 

Ointments containing fifteen to twenty grains of extract 
of opium or extract of belladonna to the ounce, may be 
applied, spread upon cloths, or rubbed in with the finger, 
when the eruption occurs on the scalp. Among pigments, 
the essential oil of peppermint, painted over the crust of the 
affected nerve, and over the vesicles, if unbroken, is a very 
good application. Perhaps, the best application of all, in 
painful herpes zoster, is the following : — 

R. Morphiae Sulphat gr. v 

Collodii f ^ ss. M. 

Put a brush in the cork. 

This may be painted over the vesicles, broken or unbroken, 
twice, or even three times, daily, and acts both as a protect- 
ive and anodyne, at the same time. 

The prognosis of herpes zoster is almost always favorable, 
the eruption running its course in a few weeks, in almost all 
cases. H. zoster of the orbital region, however, sometimes 
endangers the eye. 

Hirsuties. (See Hypertrophy of hair?) 

Hives. A popular name for various diseases of the skin, 
and other parts. In this country, sixty years ago, "Hives" 
was understood to mean what is now commonly called croup. 
Hence the name of the popular compound syrup of squills, 
"Coxe's Hive Syrup." In England, the term hives is ap- 
plied to various skin diseases, chiefly, however, to chicken- 



HORN, CUTANEOUS. 155 

pox or varicella. In this country, at the present time, a 
patient who is said to have the hives will almost invariably 
be found to suffer from urticaria. (See Urticarial) 

Hordeolum (ii), or sty, is a small boil, seated at the edge of 
the eyelids, and involving a Meibomian gland. It is not an 
active kind of boil, but progresses sluggishly, the pustule 
centre being small. It is painful, and some time elapses 
before all traces of its existence go. There may be one, two, 
or more, on one or both eyelids (T. Fox). The general treat- 
ment is that of a boil. (See Furuncle.) I have obtained the 
best results from the administration of calcium sulphide in 
doses of tV grain every hour, until ten have been taken ; to be 
repeated daily. Externally, an ointment of ten grains of red 
oxide of mercury to the ounce will be found useful in stimu- 
lating the lids to a healthy condition. 

Horn, Cutaneous (iv). Cutaneous horns, when fully de- 
veloped, differ little, as regards structure, from ordinary horns 
of animals. The excrescence is solid, hard, dry and wrinkled, 
or laminated. In form it is usually elongated and roundish, 
or conical. Sometimes it assumes a flattened or button-like 
form. The form is varied, but the horn is often twisted and 
misshapen. The color is grayish, yellowish, brownish or 
blackish. Horns may be of any size, from that of a pin's 
head to that of the finger. The base is concave or flattened, 
and rests upon the skin, which may be normal or inflamed. 
Horns are usually single, but may be multiple. They may 
occur upon any part of the body, but are commoner upon 
the face. Though commonly occurring upon elderly people, 
they are also found in the young. They are painless when 
not injured, and grow slowly, dropping off at times, when 
they have reached a considerable size, and leaving behind a 
shallow ulcer, from which the horn is again reproduced. 

The treatment of cutaneous horns is simple. The growth 
is to be twisted or cut out, and the base lightly cauterized 



156 DISEASES OF THE SKIN. 

•with caustic potassa or chloride of zinc, to prevent its repro- 
duction. The prognosis is usually favorable, but in elderly 
people epithelioma sometimes develops at the base of the 
horn. Hence, it is desirable to remove the growth and 
cauterize in every case. 

Hydroa. The name at one time given to a group of symp- 
toms now recognized as characteristic of herpes iris. (See 
Herpes iris.) 

Hyperidrosis (i). Excessive sweating. It is a functional 
disorder of the sweat glands. The affection may be very 
slight, merely manifesting itself in a dampness of the skin, as 
in those persons who suffer from clamminess of the hands or 
feet ; or it may show itself in the pouring forth of very large 
amounts. It may be acute or chronic, and it may be localized 
at certain points, as the palms or soles, which are the usual 
seat of the disease, or it may involve the whole body, as in 
pneumonia, tuberculosis, rheumatism, etc. Local hyperidrosis 
is often a disagreeable and stubborn disease. It usually occurs 
on the palms, soles, axillae and genitalia, on one or both sides. 
Cases of unilateral sweating are occasionally recorded, and the 
disease may affect an entire half of the body. The quantity 
of sweat secreted when the perspiration occurs on the palms 
or soles is usually excessive ; when affecting the former the 
sweat may at times drip from the ends of the fingers, when 
the hand is held down, as if it had just been dipped in water. 
The amount of sweat secreted at one time or another depends 
on various circumstances, as the condition of the patient, 
exercise, temperature, etc. 

In a case of well-marked hyperidrosis the skin cannot be 
kept dry, and it usually presents a whitish or yellowish color 
and a soggy, water-logged appearance. When the soles are 
affected the stockings and shoes become moist, and the latter 
especially are soaked with the decomposing secretion, and 
are apt to smell very badly, rendering the patient annoying 



HYPERIDROSIS. 157 

to himself and disgusting to others. (See Bromidrosis.') Some- 
times the epidermis of the sole peels off, and walking becomes 
difficult. The disease may last for years. When it occurs 
about the genitalia, erythema and intertrigo generally ac- 
company it, and here the greasy, easily decomposible dis- 
charge is seen to be made up of sebum, as well as sweat, 
which, doubtless, is the same, to a less degree, in other lo- 
calities. 

The causes of hyperidrosis are often difficult or impossible 
to determine. In many cases it appears to be the result of 
some disturbance of the nervous system, debility or faulty 
innervation. It occurs at all ages and in both sexes; in the 
cleanly and among the dirty alike. It is apt to be worse in 
summer. 

The treatment of hyperidrosis should usually be both gen- 
eral and local. If there be debility, tonics are called for. 
Iron, quinine, strychnia, ergot and the mineral acids are to 
be employed. Extract of belladonna, in \ to \ grain doses, 
solution of sulphate of atropia, 2^0 to fa grain four times a 
day, until its full physiological effects are produced, and fara- 
dization may be employed, at one time or another, with hope 
of success. The cause should always be looked into, and if 
this can be ascertained, the treatment should, of course, be 
directed against this. I am inclined to think that, in some 
cases, malaria may be the exciting cause. When this is found 
to be the case, large doses of quinine, combined with fifteen- 
minim doses of dilute sulphuric acid, will prove useful. 
Every hygienic means, as diet, regimen, cold bathing, fric- 
tions, etc., should be brought into use. The treatment should 
generally begin by the administration of atropia or bella- 
donna in doubtful cases. They always do good at first, and 
time is thus gained to investigate and examine into the cause 
of the malady, and to decide, perhaps, upon a less empirical 
plan of treatment. 



158 DISEASES OF THE SKIN. 

Local treatment in hyperidrosis is particularly useful, and, 
in some cases, may alone be required. Patients are apt to 
use too much water, particularly warm water, in washing the 
parts too frequently. The parts affected should be washed 
as rarely as possible — only when they are really dirty. They 
should be wiped, however, from time to time, with a damp 
cloth, and immediately dried with a soft towel, without fric- 
tion. Various dusting powders, as starch, lycopodium, mag- 
nesia and oxide of zinc, or the same with the addition of half 
a drachm of salicylic acid to the ounce may be used. They 
should be removed and renewed so soon as they become moist 
and caked. Chloral in powder, in the proportion of one 
drachm to one ounce of starch powder, is one of the most 
efficient of all these powders. They are ordinarily only ser- 
viceable in mild cases. Slight cases of hyperidrosis may also 
often be cured by the use of juniper tar, carbolic acid and 
sulphur soaps. Lotions containing alcohol, alone or with 
the addition of some astringent, will be found useful. The 
following is a convenient formula: — 

R . Acidi Tannici gj 

Alcoholis f ^ viij . M. 

Sig. — Use as a lotion. 

Salt baths are sometimes found serviceable. Tincture of 
belladonna, diluted or in full strength, may be employed, 
its constitutional effects being guarded against. Weak solu- 
tions of chloral, permanganate of potassium, and salicylic 
acid, have been employed with success. In hyperidrosis of 
the palms and soles, washing with carbolic acid or juniper 
tar soap may be followed by the application of the following 
ointment, spread upon cloths, and kept in place with a 
bandage : — 

R . Ung. Picis, U. S. P. 

Ung. Sulphuris, U. S. P. . .aa. . . ■ | ss. M. 



HYPERIDROSIS. 159 

In obstinate and severe cases, especially when the soles of 
the feet are affected, Hebra's treatment is the best. It is as 
follows : The parts having been cleansed with soap and water, 
the following ointment is applied : — 
R . Emplast. Diachyli 

OleiOlivae aS ^ iv. M. 

The plaster is to be melted, and the oil added and stirred 
until a homogeneous mass results. 

Pieces of muslin or cotton cloth are to be cut to the size 
of the parts, and the ointment spread on thickly and applied. 
Lint, smeared with the ointment, is also to be placed between 
the toes (or fingers), so that every portion of the skin may be 
completely covered with a layer of the ointment. The dress- 
ings are to be bound down closely, by means of a bandage. 
The cloths are to be changed twice in the twenty-four hours, 
when the parts are not to be washed, but simply rubbed dry 
with lint and a starch-dusting powder, after which new dress- 
ings are to be applied in exactly the same manner. This 
treatment is to be continued from one to several weeks, 
according to the severity of the case. Even when the disease 
is on the soles, the patient may be permitted to walk about 
in loose shoes. At the expiration of eight or ten days the 
parts are to be rubbed with the dusting powder and the 
dressings discontinued. The powder should be used for 
several weeks longer. Usually the sweating tends to lessen 
and gradually disappear after two or three weeks from the 
beginning of the treatment. A repetition of the course in 
severe cases is sometimes necessary before attaining a com- 
plete cure. 

Of course, the patient must give up his occupation while 
undergoing this treatment — a sacrifice of time which is im- 
possible in many cases. When, however, circumstances will 
permit, the treatment just described will succeed when milder 
measures, however faithfully applied, have failed. 



160 DISEASES OF THE SKIN. 

The prognosis of hyperidrosis depends somewhat upon the 
state of the patient's health, the duration and locality of the 
disease and its extent. Many cases are easily cured, while 
others are extremely intractable. The ability of the patient 
to follow the treatment must also be considered, as careful 
attention to the directions given is almost essential to a 
cure.' 

Hypersesthesia of the Skin (viii). Simple, augmented 
natural sensibility may be either general or local, diffused or 
circumscribed, unilateral or symmetrical. The temperature, 
as a rule, remains normal. The causes are varied, the con- 
dition being due either to some functional derangement of 
the nervous system, or to some organic disease connected 
with the nerve centres or trunks. Hysteria and allied states 
are well-known causes; also diseases of the brain, spinal cord 
and nerves. The sensation in the parts is unduly exalted, 
the patient experiencing discomfort from contact with the 
air, clothes, and other objects. The skin is often exquisitely 
sensitive to all impressions. In duration it may be permanent 
or temporary, according to the cause which has occasioned 
it (Duhring). 

The treatment of hypersesthesia and of its allied condition, 
dermatalgia, or pain in the skin, will depend upon whether 
it be idiopathic or symptomatic. Of course, the general tone 
of the system must be examined into with great care, and 
any aberration from the standard of health corrected, if pos- 
sible. The idiopathic form gets well spontaneously, in many 
cases, after a few weeks. Local applications, however, may 
be demanded for acute symptoms. Blisters to the part, the 
galvanic current, and applications containing tincture of 
belladonna, of aconite root, or of iodine, and also the essen- 
tial oils, as Japanese mint, oil of cloves, etc. Applications 
of very hot water are temporarily useful, also vapor baths, in 
general cutaneous pain. 



HYPERTROPHY OF THE HAIR. 161 

Hypertrophy of the Skin (iv). (See Callositas, Chlo- 
asma, Clavtis, Cornu cutaneum, Dermatolysis, Elephantiasis, 
Ichthyosis, Keratosis pilaris, Lentigo, Molluscum epitheliale, 
Morphoza, Ncevus pigmentosus, Scleroderma, Sclerema neona- 
torum, Verruca?) 

Hypertrophy of the Hair (iv). Hypertrophy of the 
hair or hirsuties, includes all those cases in which the hairs 
are unusually developed, as regards their size and number, 
either upon regions where the hair is ordinarily found, or in 
places where the hair is abnormal. In the works of Duhring, 
and other writers, will be found references to a number of cases 
of extreme length and abundance of hairy growth of the scalp 
and beard. When hairs, in excess, occur in connection with 
moles, the condition is termed nozvus pilosus. Trichiasis is 
the abnormality of direction of the hairs. It may occur 
anywhere, but when found on the eyelids, the hairs turning 
inward sometimes give rise to great irritation of the ball. 
Plica polonica was formerly considered a hypertrophy of the 
hair, but it is not. (See Plica polonica?) 

The removal of abnormal growths of hair occurring in 
normally hairless regions, is an operation requiring consider- 
able skill. It is done by means of electrolysis, as first sug- 
gested by Michel and Hardaway, of St. Louis. The opera- 
tion, as described by Hardaway, is performed as follows : 
A number thirteen cambric needle is attached to any con- 
venient handle, which latter is connected to the negative 
wire of a galvanic battery ; a moistened sponge electrode is 
connected with the positive pole. Under a strong lens, held 
in the left hand (or without this, if the operator has very 
good eyesight), the patient being seated in a reclining chair, 
facing a good light, the needle is entered, as near as possible, 
into the hair follicle ; after this has been accomplished, and 
not till then, the patient is told to approach the sponge 
(positive) electrode to the palm of the hand. The needle is 



162 DISEASES OF THE SKIN. 

not withdrawn until a slight frothing is observed around the 
stem, showing that the electrolytic action has been fully 
developed ; but to avoid shock, the sponge electrode is first 
released by the patient, the needle being removed subse- 
quently, being exactly the reverse of the initial steps. 

The hair should always be left in situ, and not extracted 
before the needle is introduced, as it is a guide for the intro- 
duction of the needle, the instrument being entered alongside 
of it. Besides this, it is an immediate guarantee of the suc- 
cess of the operation ; for if the hair comes away with the 
very gentlest traction of the depilating forceps, a point al- 
ways to be tested at once, we know that the papilla has been 
destroyed ; but if force is required for its extraction, it is a 
sign that the follicle has not been properly entered. In this 
case the needle is re-introduced, or better, it is not removed 
at all, repeated attempts being made, from time to time, to 
withdraw the hair, until finally it is loosened. Eight cells 
of a freshly charged galvanic battery will usually suffice. 
A greater or less number, however, may be required in one 
case or another. The operation is a painful one, and but 
few hairs can usually be removed at a sitting. 

The needle should be as fine as can be procured, even finer 
than a No. 13 cambric, if such is procurable ; and it must be 
remembered that the larger the needle, the longer it is 
retained in situ, and the stronger the battery power, the 
more rapidly and thoroughly can the hairs be removed. 
But if either of these conditions overstep the proper limits, 
abscesses and scars are apt to follow, and much unnecessary 
pain is caused. In any case, thirty or forty per cent, of the 
hairs remain (or appear to remain, for I think the growth of 
new hairs in the neighborhood is sometimes stimulated by 
the operation), and the operation must almost always be 
repeated once or several times. When carefully performed, 
not much scarring results, and I think most ladies who suffer 



ICHTHYOSIS. 163 

from the growth of a moustache or beard would prefer the 
scars. 

All other methods of removing superfluous hairs are fail- 
ures. Depilatories are temporary, vain and futile, besides 
occasionally injuring the skin. 

Hypertrophy of the Nail (iv) may occur as an 
idiopathic aifection, or it may appear in connection with 
certain general or constitutional disorders, as psoriasis, ich- 
thyosis, syphilis and leprosy. When attended by a simple 
increase in the nail substance it has been called onychauxis. 
When, as is usually the case, the nail not only increases 
in size, but becomes discolored, rough and distorted, so as 
sometimes to look like a ram's horn, it has been called 
onychogryphosis. One, several, or all the nails may be affected, 
and the toes are more apt to suffer than the fingers. The 
excessive growth may be removed by bone forceps. I do 
not think that internal treatment can much affect hyper- 
trophy of the nails. 

Ichthyosis (iv). Ichthyosis is a congenital, chronic, 
hypertrophic disease, usually occupying the whole surface, 
characterized by dryness, harshness or scaliness of the skin, 
and a variable amount of papillary growth. Two varieties 
are generally described, I. simplex and I. hystrix. I think 
the latter a distinct affection, and have described it below. I 
am now understood to speak only of ichthyosis "simplex." 
The disease may be so mild in form as to amount to little 
more than a certain dryness and roughness of the skin. It 
may, on the other hand, be quite severe. As ordinarily met 
with, ichthyosis consists of an altered state of the skin, char- 
acterized by a harsh, dry condition of the whole surface, 
accompanied by the production of scales, sometimes firm and 
brawny ; at other times coarser, and shaped after the lines 
and furrows of the skin. The latter, from their resemblance 
to fish scales, have given occasion to the name of the disease, 



164 DISEASES OF THE SKIN. 

"ichthyosis," or the "fish-skin" disease. The amount of 
scales depends upon the age of the patient, the severity of 
the disease, and the efficiency of any treatment which may 
have been employed. The scales, if not removed by bathing, 
often tend to accumulate. They are usually whitish, grayish 
or yellowish in color, with sometimes a glistening look. 
Sometimes the general color of the eruption is of a more or 
less yellowish or dark olive green. Even when the disease 
is not severe, it gives the surface an unwashed look. 

The localities in which ichthyosis is developed to the most 
marked degree are the lower extremities, from the hips to 
the ankles, and the arms and forearms. The skin of the 
backs of the hands and the face very often has a peculiar, 
smooth-drawn, parchment-like appearance, which is very char- 
acteristic. Sensible perspiration is, in most cases, absent, 
excepting in the face, axillae, palms and soles. There is 
sometimes marked hyperidrosis in the two last. The disease 
is worse in winter than in summer ; in fact, it is apt to 
almost disappear during the latter season. The course of the 
disease is essentially chronic. Beginning to show itself dis- 
tinctly during early childhood, it grows more and more 
marked with each year of the patient's life. It sometimes 
appears to be hereditary, but no distinct and invariable 
hereditary influence seems to prevail in all cases. Ichthyotic 
parents usually beget healthy children. The patient himself 
generally enjoys fair or good health. The disease occurs in 
all races, both sexes, and in every grade of society. 

The diagnosis of ichthyosis is usually not difficult. The 
history alone differs from that of all other skin diseases, its 
chronicity offering a marked contrast to the rapidly develop- 
ing character of the acute inflammatory disorders. 

External treatment alone is of any avail in ichthyosis. 
No medicine as yet brought forward has influenced the 
condition of the skin in this disease. Therefore, time, 



ICHTHYOSIS. 165 

money, and the patient's stomach, will be saved, if arsenic, 
cod-liver oil, and what not, be discarded from the beginning. 
The skin is to be kept moist and supple by the frequent 
administration of warm baths with alkalies or soap. Vapor 
baths are also useful. Inunctions of some emollient material 
should always be practiced after the bath. In well-marked 
and severe cases, the soap treatment will be found valuable, 
to remove some of the dry and horny epidermis, and prepare 
the way for the application of emollients. A sufficient quantity 
of sapo viridis is to be rubbed into the skin twice, daily, for 
four or six days, during which period the patient is to refrain 
from bathing. A bath is first to be taken, four or five days 
after the last rubbing, when, in fact, the epidermis has begun 
to peel off; afterwards, inunction with a simple ointment is 
to be practiced, in order to prevent Assuring of the new skin. 
For this purpose, oil of sweet almonds, glycerine, pure or 
diluted, with one to seven parts of water, or one of the 
following ointments may be used : — 

R. Adipis Benzoatse 3j iv 

Ung. Petrolii |}j 

Glycerinae J} iv. M. 

Or, 

R. Potassii Iodidi J}j 

01. Pedis Bubuli, 

Adipis aa ^ss 

Glycerinae fgj. M. 

I have used the latter formula with satisfaction in a number 
of cases, while I must confess ignorance as to the part played 
by the iodide of potassium. 

The prognosis of ichthyosis is entirely unfavorable as 
regards permanent cure, but alleviation of the symptoms 
may be brought about very satisfactorily. The affection 
should really be regarded as a deformity rather than a dis- 
ease, though it predisposes strongly to the occurrence of 
eczema, particularly of the hands. 



166 DISEASES OF THE SKIN. 

Ichthyosis Hystrix (iv) is characterized by the formation 
of irregularly shaped and sized, ill-defined, rough, harsh, yel- 
lowish, brownish or greenish patches, made up of enormously 
hypertrophied, more or less horny papillae. Unlike the or- 
dinary form of ichthyosis, this is apt to be localized, and 
rarely covers the surface to any extent. It is sometimes dis- 
tributed in the line of the nerves. Sometimes the papillae 
are so hypertrophied as to stand out like porcupine quills — 
hence the name "hystrix." 

The treatment of ichthyosis hystrix is essentially that of 
any warty or horny, non-malignant growth. The patch, if 
not too large, may be poulticed until softened, and then 
attacked by caustic potassa, or glacial, acetic, or chromic 
acid ; or it may be removed by the knife. In one case con- 
siderable improvement was gained by painting the surface, 
twice daily, with the following : — 

R. Acidi Salicylici £ss 

Ext. Cannabis Ind gr. x 

Collodii gj. M. 

Another preparation which has been used with good effect 
is the fluid extract of Thuja occidentalis, painted on in the 
same way. 

Impetigo (ii) is an acute inflammatory disease, character- 
ized by the appearance of one or more pea- or finger-nail sized, 
discrete, rounded and elevated, firm pustules, unattended, as 
a rule, by itching. The eruption is occasionally, but not 
often, attended by slight constitutional symptoms, as loss of 
appetite, constipation and malaise. The pustules come out 
one or two at a time, and are discrete and scattered, never 
tending to coalesce. They are tense, raised, semi-globular, 
of a whitish-yellow color, and at first surrounded by an 
areola, but with little infiltration. In number they may vary 
from one to a dozen, or more. They may occur upon any 
part of the body, but are common upon the face, hands, feet, 



IMPETIGO. 167 

toes and lower extremities ; also, upon the palms and soles. 
Commonly they itch or burn little or not at all. The disease 
may last several weeks, the lesions coming out rapidly one 
after another at first, lasting a day or two in a typical con- 
dition, and then becoming darker or bloody, drying, crusting 
and becoming absorbed. The fluid contents of the pustules, 
where these are ruptured by accident or design, are seen to be 
thinner than would appear from the firm aspect of the unrup- 
tured pustule. The crusts may be abundant, and of a yel- 
lowish or brownish color, or they may be insignificant, the 
pustule being absorbed. In no case does a permanent scar 
remain. The disease tends to a speedy recovery. Relapses 
are not common. 

Impetigo occurs in healthy, well nourished people. Its 
exact etiology has not been ascertained, but it is not con- 
nected with debility, want of proper nourishment, or de- 
rangement of the digestive system. In adults it occurs about 
the fingers and hands, but it is not so common among grown- 
up people as among children. It is not contagious. 

Impetigo is to be distinguished from eczema, impetigo 
contagiosa, and ecthyma. From eczema it is distinguished 
by the superior size and development of the pustules, their 
small number and separate arrangement. In addition, the 
pustules of impetigo do not incline to rupture, and there is 
rarely a crusted discharge. The opposite in all these respects 
is found to occur in eczema. In addition, eczema is in- 
variably accompanied by infiltration and by itching, neither 
of which are present in impetigo. In impetigo contagiosa, 
which must not be looked upon as a variety of impetigo, 
but as a distinct disease, the affection begins by a vesicle or 
vesico-pustule like that of vaccinia, the crust is flat, some- 
times umbilicated, without any infiltration about its base ; 
and above all, there is a history of contagion. None of these 
characters are found in impetigo. Impetigo is often con- 



168 DISEASES OF THE SKIN. 

founded with ecthyma, but in the latter affection the pustules 
are flat, and are surrounded by an extensive, inflammatory, 
hard base ; in impetigo they are elevated and rounded, and 
have generally but a slight areola. In ecthyma the crusts are 
blackish or brownish in color, are large and flat, and are 
seated on a deep excoriation. Impetigo usually occurs in 
the strong and healthy ; ecthyma in the weakly and ca- 
chectic. 

The treatment of impetigo is simple. The pustules may 
be opened as they mature, and the contents allowed to escape. 
The part should be protected from rubbing and violence. 
The lesions may be dressed with the following ointment : — 

IJ. Bismuthi Subnitrat 3 ss ~j 

Ung. Aquae Rosoe ^ j. M. 

This ointment is to be spread thickly on bits of cloth, 
applied to the lesions and covered with waxed paper. It is 
then to be bandaged on to the parts, and retained in apposi- 
tion with occasional renewals, until the lesions have healed 
up under the crust. 

Internal treatment is not required. 

Impetigo Contagiosa (ii) is an acute, inflammatory, 
contagious disease, characterized by the formation of one or 
more superficial, discrete, roundish or ovalish, vesico-pustules 
or blebs, the size of a split pea or finger nail, which pass into 
crusts. The eruption is commoner among infants and young 
children. Isolated, flat, or slightly raised vesicles are first 
seen, small in size at the beginning, but rapidly spreading on 
the periphery until they become like little blebs, with a thin, 
withered-looking, collapsed wall. The lesions are few in 
number. Usually they are discrete, but sometimes two or 
more coalesce. They are most commonly found about the 
mouth, on the chin and nose, and on the hands. Crusts 
form in a few days, usually yellowish or straw-colored, and, 
as they dry, loosening at the edges, so as often to look as if 



IODINE ERUPTIONS. 169 

they had been stuck on the skin. The surface beneath is 
moist and excoriated. The mucous membranes of the mouth 
and conjunctiva are occasionally invaded. The disease may 
extend from place to place by auto-inoculation. It runs its 
course in about ten days, tending to a spontaneous recovery. 
Sometimes, however, it runs an anomalous course. 

Impetigo contagiosa is ordinarily a disease of the lower 
classes, and its spread is favored by want of cleanliness. It 
is almost exclusively confined to children. The disease is 
contagious and auto-inoculable. It appears sometimes to occur 
in the form of an epidemic, and is commoner in summer. 
The affection has been supposed to be due to a vegetable 
fungus, but thus far the evidence of observers has been un- 
certain and conflicting. Stelwagon, whose opportunities of 
observation of the disease have been greater than those of 
any previous writer on the subject, does not consider the 
disease to be due to a parasite, nor related in any way to 
vaccination. He believes it to be an acute, contagious, sys- 
temic disease (exanthem), with cutaneous manifestations, 
having a definite course, and, in all probability, due to a 
specific poison. 

Impetigo contagiosa is to be distinguished from eczema 
pustulosum and from impetigo ; the history, character and 
course of the lesions will settle the question. From varicella, 
pemphigus and herpes iris, the appearance and distribution 
of the lesions will distinguish the affection. 

The treatment of impetigo contagiosa is simple. An oint- 
ment of ten grains of ammoniated mercury to the ounce is as 
good a dressing for the lesions as is necessary, and this, with 
cleanliness, will suffice for a rapid cure. 

Impetigo Herpetiformis. (See Dermatitis herpetiformis?) 

Infantile Syphilis. (See Syphilis ; shin diseases in infants?) 

Intertrigo. (See Erythe?na intertrigo?) 

Iodine Eruptions. (See Dermatitis medicamentosa?) 

12 



■™ 



170 DISEASES OF THE SKIN. 



Itch — Army Itch. (See Scabies.') 

Keloid (vi). Keloid is a connective-tissue new growth, 
characterized by one or more irregularly-shaped, variously- 
sized, elevated, smooth, firm, somewhat elastic, pale-reddish, 
cicatriciform lesions. 

The disease usually begins as a small, pea-sized nodule, 
increases slowly in size and commonly assumes an ovalish, 
elongated or crab-shaped form, or may occur in streaks or 
lines. The lesion varies greatly in shape, and may be quite 
small or as large as the palm. The outline is well-defined, 
and the surface contour rounded and highest in the centre. 
Taken between the fingers it has a firm, dense, slightly elastic 
feel. Its surface is smooth, shining and generally devoid of 
hair, and its color reddish or pinkish. The lesion is usually 
single, though several may exist simultaneously. It is more 
common over the sternum, but it is also met with on the 
mammae, neck, ears, arms and elsewhere. It is sometimes 
painful, especially on pressure, and occasionally, but rarely, 
it itches. The course of the disease may be rapid or slow ; 
having attained a certain growth it is apt to be stationary, 
and may remain a lifetime, though it generally disappears 
spontaneously. 

Keloid, it is said, may arise spontaneously. It usually, 
however, springs up at the site of various injuries of the skin, 
when it is called cicatricial keloid. This variety is often met 
with as the result of burns by fire or chemicals, cuts, flogging 
and wounds of all kinds. It is sometimes found in the lobe 
of the ear after piercing for ear-rings, in the scars of leech 
bites, or of acne lesions, and I have seen it abundantly de- 
veloped in the scars of non- parasitic sycosis and of syphilis. 
I think that in these last instances the keloid lesions tend to 
disappear rather more rapidly than in other forms. Keloid is 
commoner in the colored race. No cause can be ascribed for 
the " spontaneous " form of keloid, and I do not believe such a 






KELOID. 171 

variety exists ; each lesion of keloid grows in some previously 
existing scar, which, however, may have been so minute as to 
have escaped notice. 

Keloid is a connective-tissue new growth. Under the 
microscope the lesions are seen to be made up of a dense, 
fibrous mass of tissue, whitish in color and composed of 
compact bundles of connective tissue, having their seat in 
the corium. 

The symptoms of keloid are so striking that no difficulty 
need be experienced in making a diagnosis. It is most liable to 
be mistaken for simple cicatrix, from which it may be distin- 
guished by its color, outline, elevation and consistence, and, 
frequently, by the presence of pain. 

The treatment of keloid is rarely satisfactory. When ope- 
rated upon by the knife or caustic it is apt to return, and 
frequently in an aggravated form. Caustic potassa is the best 
caustic to use, but the growth should never be touched while 
it is still making progress, or certain disappointment will be 
the result. Hypodermic injections of morphia are occasionally 
required to allay the pain. Chloroform and anodyne liniments 
may also be prescribed for the same purpose, and I have used 
the fluid extract of hamamelis with benefit. Wilson recom- 
mends painting the growth with a solution containing one 
drachm of iodide of potassium, an ounce of soft soap and an 
equal quantity of alcohol ; followed by the application of 
lead plaster spread on a piece of soft leather, the dressing 
being kept on a week and then replaced by another. 

The prognosis of keloid is not very favorable as to dis- 
appearance. The utmost that can be said in any given case 
is that it may disappear either spontaneously or under the use 
of supposed remedies after a time. Its course is usually 
progressive, with occasional temporary arrest of development. 
Very often, however, the lesions may remain stationary for 
years. 



172 DISEASES OF THE SKIN. 

Keloid of Addison. (See Morphcea.) 
Keratosis Pigmentosa. (See Verruca senilis.*) 
Keratosis Pilaris (iv) is somewhat akin to ichthyosis. 
It is characterized by the formation of pin-head sized, conical, 
whitish, epidermic elevations, seated about the apertures of 
the hair follicles, chiefly those of the outer aspect of the 
thighs and of the arms near the shoulders. It looks not unlike 
" goose flesh." The treatment is in general the same as that 
of ichthyosis, but the prognosis is more favorable. Daily 
rubbings with sapo viridis, followed by an emollient ointment, 
are usually useful. 

Lentigo (iv), or freckles, though a common affection, is 
so unimportant as to demand only a passing notice. Their 
ordinary seat is upon the face, but they may occur in any 
part of the body. They are rarely seen before the third year, 
and tend to disappear spontaneously in older persons. Freckles 
of an intense dark-brownish or blackish color are met with as 
one of the symptoms in the rare disease known as " xero- 
derma of Hebra." (See Atrophy of the Skin.) The remedies 
employed in lentigo are the same as those used in chloasma. 
(See Chloasma.) 

Lepra. Lepra is an endemic, chronic, malignant, con- 
stitutional disease,characterized by alterations in the cutaneous 
nerve and bone structures, resulting in anaesthesia, ulceration, 
necrosis, general atrophy and deformity. Leprosy is a con- 
stitutional disease and involves the whole organism most pro- 
foundly. Its invasion is slow and insidious. Premonitory 
symptoms of malaise, mental depression, languor, sleepiness, 
loss of appetite, nausea, chills, repeated attacks of fever, gen- 
eral debility, nervous prostration and pains in the bones are 
usually present and may last for weeks, months or years, 
without other symptoms. Sooner or later, however, the more 
characteristic features of the disease, the bullous, macular, 
pigmentary or tubercular skin lesions, make their appearance. 



LEPRA. 173 

These may appear separately, successively or together. Some- 
times the skin lesions are prominent symptoms of the disease ; 
at other times they are subordinate. Other organs of the 
body, as the nerves, are also affected. 

Two forms of leprosy are recognized, the tubercular and 
the anaesthetic. No absolute line, however, separates them ; 
they often appear simultaneously upon different parts of the 
body, and one may pass into the other. The tubercular 
variety is characterized by the formation of masses of infiltra- 
tion and tubercles. Other lesions are also found. An erup- 
tion of pemphigus-like blebs, showing themselves irregularly 
for some time before the appearance of other lesions, is one 
of the earliest symptoms, though it is said these more fre- 
quently precede the macular variety of leprosy than the 
tubercular. Macules now make their appearance as smooth, 
shining, erythematous patches, usually defined infiltrated, not 
commonly raised above the level of the skin, yellowish or 
reddish in color, and growing dusky yellow and brownish, 
as they grow older. Sometimes they are paler, and look like 
a piece of cut raw bacon set into the skin. They are com- 
monly surrounded by a pinkish or lilac border of small blood 
vessels. The sensibility of the skin is altered from the begin- 
ning, the patches being at first hyperaesthetic, and later 
anaesthetic. They may appear anywhere on the body, but 
most commonly upon the trunk and extensor surfaces of the 
extremities. Sometimes they are present in such numbers as 
to involve a considerable area of the body. They may dis- 
appear and reappear from time to time, or they may remain 
as permanent lesions, in which case they increase in size. 

Sooner or later the disease shows itself in the form of 
variously-shaped and sized nodules and tubercles, situated in 
the skin and subcutaneous tissues, which may develop into 
roundish, irregularly-shaped prominences and elevated masses, 
from cherry to walnut size, or larger, conspicuous and promi- 



174 DISEASES OF THE SKIN. 

nent, or slightly raised, and having a yellowish-brownish or 
bronze color. They are more or less painful when pressed 
upon. They are usually found upon the face; and chiefly the 
forehead, eyebrows, cheeks, nose, lips, chin and ears are apt 
to be invaded, giving rise to deformity, often of a hideous 
character. Later, the mucous membrane of the mouth, 
pharynx, epiglottis, larynx and nares are attacked ; the eye 
also suffers. Besides the face, other portions of the body, 
notably the trunks, buttocks, arms and legs, fingers and toes, 
are invaded. The course of the tubercle varies ; it may last 
a long time without change, or it may soften and ulcerate at 
once, or it may be absorbed. Ulceration is apt to occur 
about the fingers and toes, the ulcers being covered with 
adherent brownish crusts. 

The anaesthetic variety of leprosy may occur in conjunction 
with the tubercular variety, or alone, in which case it is 
characterized by the presence of a number of symptoms in 
addition to the anaesthesia. Blebs are apt to appear, first 
coming out in an irregular manner, from time to time, and 
being followed by pigmentation, and, after a longer or shorter 
time, by anaesthesia about the seats of the former lesions. 
In other cases, macules, like those which sometimes precede 
the tubercular form, come first. Hyperaesthesia of the skin 
sometimes occurs, with pains and burning sensations, followed 
by anaesthesia affecting a limited portion or the greater part 
of the surface. Later, the skin becomes atrophic, dry, yellow- 
ish or brownish in color, or more or less wrinkled. 

Following this alteration in the structure of the skin, the 
subcutaneous tissues and muscles undergo atrophy, giving rise 
to deformity, especially of the fingers and toes ; the hairs and 
nails become altered in structure or are shed : the hands and 
feet become greatly mutilated ; the fingers and toes bent, 
crooked and contracted. Sooner or later the bones are 
attacked, causing destruction of the joints and of the bones 



LEPRA. 175 

themselves ; the skin over the joints becomes excoriated and 
ulcerated ; the ends of the bones undergo disintegration, and 
the phalanges, finally, either become absorbed or drop off. 
Even the hands and feet may gradually be lost ; the ex- 
tremities become more or less completely anaesthetic, and are 
greatly wasted, at times, to half their former size. 

The causes of leprosy still remain obscure. It is endemic 
in Africa, along the shores of the Mediterranean, and of the 
Atlantic and Indian Oceans, as well as in the interior of the 
country; also in Asia Minor, Arabia, Persia, India, China, 
Japan, Kamtschatka, the various islands of the Pacific Ocean 
and Australia. In Europe, it is found in Norway, Southern 
Spain, Sicily, Greece, and Southern Russia. Upon the West- 
ern Hemisphere, it occurs in Mexico, Central America, the 
Islands of the West Indies, along the coast of South America, 
and especially in Brazil ; it also exists in Iceland. Within 
the past few years, cases of undoubted authenticity have 'been 
reported as occurring among natives of the United States, 
who have never been out of the country. 

Leprosy is in many instances hereditary, and may be con- 
veyed from parent to child through a series of generations. 
Concerning its contagiousness opinions differ, and although 
the weight of testimony seems in favor of its contagious 
nature, the matter cannot as yet be said to be definitely 
settled. The most potent causes in the production of the 
disease appear to be connected with climate, state of the soil, 
food, and habits of the people. The disease usually occurs 
among the lowest classes, but it may attack those in the most 
favored circumstances. It occurs in both sexes, and at any 
period of life. 

The diagnosis of leprosy, in countries where the disease is 
endemic, is usually easily made. The earliest premonitory 
symptoms arouse suspicion, which the appearance of the 
cutaneous manifestations places beyond doubt. When the 



176 Diseases of the skin. 

disease occurs sporadically, in countries where it is not en- 
demic, it may, however, be mistaken for other affections. 

The macular and tubercular varieties are apt to be mis- 
taken for syphilis. The lesions of leprosy, however, are 
larger and more irregular in size and distribution. The pig- 
mentation of leprosy is of a peculiar yellowish or brownish 
tint. The lesions have a smooth, glazed appearance. The 
tubercles are apt to be much larger than those of syphilis, 
being often hazel-nut or walnut-sized, and are darker in 
color ; their course is usually slower than that of syphilitic 
tubercles. The general expression of the face (the usual seat 
of the tubercles in leprosy), is much changed, the features 
having an ugly, leonine appearance. 

Later, when the tubercles break down into ulcers, the 
blackish, adherent crusts which cover them are seen to be less 
bulky than those observed in syphilis. With ulceration come 
other very marked features of the disease, as anaesthesia, dis- 
tortion of the hands and feet, absorption of bone tissue, and 
atrophy, all unmistakably characteristic. 

The yellowish, roundish patches of macular leprosy should 
not be mistaken for vitiligo, although this may readily occur 
in the early stages of the disease. The health in vitiligo is 
generally good, and the decolorized patch of disease consists 
of simple absence of pigment, with usually a border of in- 
creased amount of coloring matter. The skin is normal in 
texture. In leprosy, on the other hand, the macules are 
infiltrated with a lardaceous-looking substance, of firm con- 
sistence, and are generally anaesthetic or hyperaesthetic. 

Morphcea, which is an affection of an entirely different 
nature (see Morphcea), presents lardaceous-looking patches, 
somewhat resembling those of macular leprosy. But the gen- 
eral health in morphcea is good, and the patches show normal 
sensibility, and tend to spontaneous recovery. 

The treatment of leprosy has thus far proved very unsatis- 



LEPRA. 177 

factory. As in the case of most diseases refractory to treat- 
ment, the remedies and pretended cures have been exceedingly 
numerous, but as they have failed for the most part, they need 
not be mentioned here. The remedies now employed are 
valuable in improving the general condition of the leper. 
Change of climate and residence, usually to a temperate and 
bracing atmosphere, is imperative. Strict hygienic rules 
should be adopted, including exercise and bathing, with the 
most nourishing food. Quinine and strychnia are important 
as tonics, and the usual alteratives may also be employed. 
Symptoms are to be treated as they arise. 

Local treatment is valuable. Baths, plain or medicated 
with iron or sulphur are said to be of service. (?) Of recent 
remedies, the oil of cashew nut, gurjon oil and chaulmoogra 
oil, internally and in the form of inunctions, are recom- 
mended, on good authority. The formula for the use of gurjon 
oil is as follows: — 

R. 01. Gurjon j|j 

Aquae Calcis t ^iij. M. 

Churn well together, to make a cream. Apply to ulcers. 

Cashew-nut oil is applied, pure or diluted with almond oil, 
to the anaesthetic patches, being rubbed in until it nearly 
blisters. I think one part of the cashew-nut oil to three of 
the almond oil is strong enough to begin with, and as much 
friction, short of actual blistering or abrasion of the skin, 
should be used, as the patient can bear. The oil of cashew- 
nut should also be applied, pure, to the tubercles until they 
open, and then the sores may be dressed with gurjon oil, as 
above. 

The prognosis of leprosy is unfavorable. A few cases of 
cure have been reported, when the patient has been placed 
upon energetic treatment from the earliest appearance of the 
disease. In the anaesthetic form of the disease the prognosis 
is more favorable. Patients need not be isolated unless there 



178 DISEASES OF THE SKIN. 

are open sores. I cannot believe the anaesthetic form con- 
tagious. 

Leprosy. (See Lepra.) 

Leucoderma. (Congenital, see Albinism; acquired, see 
Vitiligo.) 

Lice. (See Pediculosis.') 

Lichen Pilaris. (See Keratosis pilaris?) 

Lichen Planus. (See Lichen ruber.) 

Lichen ruber (ii). Lichen ruber is an inflammatory dis- 
ease, characterized by pin-head or pea-sized, flat and angular, 
or acuminated, smooth and shining, or scaly, deep red, dis- 
crete or confluent, papules, running a chronic course, and 
attended by more or less itching. 

The acuminated form is rare. The angular form, lichen 
ruber planus, is that commonly met with, the papules varying 
in size from a pin head to a split pea ; often they coalesce 
and form patches. The shape of the papules is peculiar and 
characteristic ; they are seldom round, as most papules, but 
are, instead, quadrangular or polygonal in form. They rise 
abruptly from the skin to the sixteenth of an inch or less, 
are flattened on the summit, and show a minute umbilication 
with whitish puncta. To the touch, they are firm, smooth, 
and without scales, excepting in those cases where the disease 
runs into a papulo-squamous stage. They are glazed, and of 
a peculiar dusky, crimson, or even violaceous tint. Usually 
discrete, the lesions are sometimes aggregated, so as to form 
sheets of raised and infiltrated lesions. 

The diffused form of the disease is rarely seen in this 
country. It is made up of large patches of acuminated lesions. 
Itching is generally present in both varieties of the disease. 
It is usually moderate, but may at times be severe. The 
commonest locality of lichen ruber planus is on the fore- 
arms, especially upon the flexor surfaces of the wrists. It 
occurs also on the palms and soles, and on the penis. It is 



LICHEN RUBER. 179 

apt to be symmetrical, and the lesions are sometimes arranged 
in rows. The course of the disease varies ; in some cases, 
under careful treatment, a cure can be effected in a few weeks 
or months, while other cases run an exceedingly chronic 
course, even extending to years. Persistent, dark brown or 
violaceous stains succeed the lesions. The severer forms are 
said to run a graver course, and to end sometimes in maras- 
mus and death. 

The cause of lichen ruber is generally to be found in 
exhaustion, nervous debility and depression, overwork and 
improper diet, leading to impoverished nutrition. 

Lichen ruber may be mistaken for the papular syphiloderm, 
which it closely resembles, especially in the coppery or ham 
color of the lesions. In the variety L. planus, however, 
the peculiar shape and contour of the lesions, with their 
smooth, umbilicated or punctate surfaces, will serve to distin- 
guish them. Eczema papulosum, which often resembles lichen 
ruber, differs, in that the papules are roundish, somewhat 
acuminated, bright red in color, and intensely itchy. Their 
evolution also is different. 

The internal treatment of lichen ruber should be chiefly 
tonic and supporting. Arsenic is of high value, and is, in 
fact, almost a specific. The dose at first, two to four minims 
of Fowler's solution, in a fluid drachm of wine of iron, should 
be increased almost to the limit of tolerance, and persisted 
in. Arsenic may also be administered hypodermically, using 
one part of Fowler's solution and five parts of water, begin- 
ning with four or five minims of the mixture. The prepara- 
tions of iron and cod-liver oil are also useful. Treatment 
should be instituted early in the course of the disease. Cases 
of long standing are very stubborn, even to the best directed 
treatment, which, earlier given, might have proved effectual. 

Locally, simple ointments, as vaseline or cold cream, may 
be employed when itching is not present. When the eruption 



180 DISEASES OF THE SKIN. 

itches, alkaline baths, carbolic acid washes or ointment, dilute 
hydrocyanic acid, with water, diluted liquor picis alkalinus, 
made thus — 

R. Potassae Caustic gr. xv 

Picis Liquidae gr. xxx 

Aquae f^ lv - M. 

may be employed. 

The following ointment is a useful one: — 

R . Olei Rusci Crudi ( Vel. 01. 

Betulae) gj 

Ung. Aquas Rosae ^j 

01. Rosae TT\xx. M. 

In addition to these the more stimulating and stronger anti- 
pruritic remedies mentioned under the head of eczema may 
be employed, with the hope of reducing the pruritus and 
bringing about absorption of the lesions. In the acuminate 
form of lichen ruber the following ointment has proved of 
high value: — 

$. Hydrarg. Bichlor gr. ij 

Acidi Carbolici gr. x 

Ung. Zinci Oxidi ^ j. M. 

The prognosis of lichen ruber will depend upon the extent 
of the eruption, its duration, and the patient's general con- 
dition. Localized eruptions on the wrists and forearms, 
occurring in persons of average health, do not usually require 
a very lengthened course of treatment for their cure. When, 
however, the eruption is extensive and severe, and has lasted 
a long while, the prognosis is much less favorable. 

Lichen Scrofulosus (ii) is a very rare disease in this 
country, and is characterized by the appearance of pin-head- 
sized papular lesions, of a reddish color, and tending to form 
in groups over the chest, back and abdomen. It resembles 
papular eczema, but does not itch. It occurs in scrofulous 



LUPUS ERYTHEMATOSUS. 181 

young persons about the age of puberty. The disease always 
yields to treatment. Cod-liver oil, internally and externally, 
cures it. 

Lichen Simplex was the name formerly given to papular 
eczema. (See Eczema?) 

Lichen Tropicus. (See Miliaria.) 

Lineae Albicantes. (See "Strice et Macula Atrophica" 
under the head of Atrophy of the skin.) 

Lip, Fissured. (See Eczema of lip.) 

Liver Spots are either discolorations of the skin (see 
Chloasma, Lentigo), or are due to a local parasitic disease 
(see Tinea versicolor). 

Louse. (See Pediculosis.) Body 1., P. corporis. Head 
1., P. capitis. Crab 1., P. pubis. 

Lupus Erythematosus (vi). Lupus erythematosus is a 
cellular new growth, characterized by one or more circum- 
scribed, roundish or irregularly-shaped, variously-sized, red- 
dish patches, covered with grayish or yellowish, adherent 
scales. The disease usually begins in the form of one or 
more roundish, pin-head to small pea-sized, erythematous 
patches, which enlarge upon their periphery, and often coal- 
esce to form larger, irregularly-shaped patches. After a time 
the patches increase in thickness, and show more infiltration, 
and when fully developed there may be a number of patches, 
varying in size from a split pea to a silver dollar, or the palm 
of the hand, having usually a distinct and clear cut marginal 
outline. In color they are reddish or violaceous, and are 
invariably covered with fine or coarse, grayish or yellowish, 
remarkably adherent scales, at times scanty, at other times 
forming sebaceous-looking crusts, like those found in sebor- 
rhea of the face. They are firmly attached to the openings 
of the sebaceous glands, which are often plugged up with 
sebum, or denuded and patulous. The patch spreads on its 
margin, which is usually higher than the centre, the latter 



182 DISEASES OF THE SKIN. 

being commonly paler, and often showing atrophic depres- 
sion. After a variable time the patch attains a certain size, 
and may remain stationary. There is never any moisture or 
discharge in connection with the disease. 

Lupus erythematosus is usually found upon the face, one 
or both cheeks, below the eyes, and the bridge of the nose, 
being the commonest seat of the affection. Often both of 
these localities are attacked by the disease, which forms the 
rude figure of a butterfly with outstretched wings. The 
muco- cutaneous and mucous surface of the lips, the ears, 
scalp, back, and other parts of the body may be attacked. 
Lupus erythematosus is remarkable for its chronicity, and 
may persist through life. It tends to increase, from time to 
time, by repeated attacks. Ultimately, the process generally 
ends in the formation of a superficial or deep-seated cica- 
tricial tissue. 

The subjective symptoms vary in different cases, depending 
somewhat upon the activity of the disease. At times there is 
much burning and itching, while in other cases there may be 
no subjective symptoms. 

The causes are obscure, although it is apt to occur in per- 
sons of a scrofulous tendency. Females are more liable to it 
than males, and light than dark-haired persons, and it occurs 
notably on those who are subject to disorders of the sebaceous 
glands, sometimes, indeed, appearing to originate in a patch 
of localized seborrhcea. 

When fully developed, the typical patch of lupus erythe- 
matosus offers such a striking picture, with its reddish or 
violaceous color, its sharply circumscribed outline, its infil- 
trated surface, studded with plugged-up or gaping sebaceous 
openings and covered with adherent sebaceous scales, and its 
place of election, the nose and cheeks, that it can scarcely be 
mistaken for any other disease. It is to be distinguished from 
lupus vulgaris by the absence of papules, tubercles and ulcer- 



LUPUS ERYTHEMATOSUS. 183 

ation. The sebaceous glands are not affected in lupus vul- 
garis. Lupus erythematosus rarely begins before puberty ; 
lupus vulgaris usually begins in childhood. Lupus vulgaris is 
a deep-seated disease, and is attended, sooner or later, with 
ulceration and disfiguring cicatrices ; lupus erythematosus is 
comparatively superficial. Psoriasis sometimes resembles 
lupus erythematosus very closely, but may be distinguished 
by its course and by the various symptoms peculiar to it. 
Syphilis sometimes resembles lupus erythematosus super- 
ficially, but its history is very different. 

The results of treatment in lupus erythematosus are ex- 
tremely varied. At one time the therapeutic measures em- 
ployed will prove rapidly and easily successful, while in 
another apparently equally light case every known method of 
treatment may be exhausted without producing more than a 
temporary effect on the course of the disease. Internal reme- 
dies are called for in some cases. They are to be selected to 
meet the especial indications which may be manifested. 
Iodine, arsenic, iodide of potassium and cod-liver oil may, 
one or another, often be employed with advantage. Hygienic 
measures, chiefly nourishing diet, fresh air and sea bathing, are 
important. 

The external treatment is that which will usually be found 
most available and of the greatest value. In the milder 
forms of the disease it is to be remembered that patches often 
disappear without leaving a scar. Care must be taken, there- 
fore, not to make matters worse than they would naturally 
turn out. No strong caustics are to be used in such cases. 
Stimulating applications may be first tried. The follow- 
ing mild stimulant is useful when the patches are more 
erythema-like in appearance, recent, spreading and superfi- 
cial, with little infiltration and no involvement of the seba- 
ceous glands : — 



184 DISEASES OF THE SKIN. 

R. Zinci Sulphat., 

Potassii Sulphuret aa..... gss 

Aquae Rosse f ^iiiss 

Alcoholis f ^ iij . M. 

If this is too strong it may be diluted, but if it agrees, the 
first two ingredients may be increased in quantity to one 
drachm. 

A somewhat stronger stimulant, but one useful in the form 
of lupus erythematosus just described, as well as in cases where 
there is more infiltration, is the following: — 

R. Chrysarobin ^iiss 

Acidi Salicylici, 

Pulv. Galaminis aa gss 

^Etheris 3J 

Collodii Flexile 3 v. M. 

Sapo viridis is also a good stimulant application, relieving 
the disease by itself alone, when used in mild cases. It may 
be applied spread upon cloth in the form of a plaster, or 
rubbed in with water. 

Dissolved in one-half its weight of alcohol, it forms the 
" spiritus saponis kalinus," of even more value as an out- 
ward application. The patches are to be well scrubbed with 
the spirit, until any scales that may be present are removed, 
when it may be washed off with water, and some mild oint- 
ment applied. Mercurial ointment is useful in some cases, 
prepared as a plaster, and applied continuously. Sulphur 
may sometimes prove serviceable applied in the form of an 
ointment, a drachm or more to the ounce. Pyrogallic acid 
has been used with success in the form of an ointment, a 
scruple to a drachm to the ounce. Stronger and even caustic 
applications are demanded in some cases, but they should 
never be used until the weaker ones have been tried. A 
solution of caustic potassa, one part to three or six of water, 
is one of the best of these. It may be applied by means of 



LUPUS VULGARIS. 185 

a charpie brush upon a stick. Fuming nitric acid may also 
be used ; it is less painful than the potash. The galvano- 
cautery has sometimes been used with success, as also has the . 
curette or scraping spoon, but in cases demanding, from their 
extent and infiltration, such strong measures, the practice of 
linear scarification is better than any of the caustics, or other 
strong remedies just mentioned. This may be carried out by 
using a fine scalpel or tenotome, holding it in the hand like 
a pen, and making a series of parallel incisions about one- 
sixteenth of an inch apart, and extending entirely through 
the skin. Having covered the patch to be operated upon 
with a series of incisions running in one direction, a fresh 
series, perpendicular to the first, should follow, and even a 
third series may be practiced, until the diseased skin is fairly 
hashed up by the knife. Excepting in persons of particularly 
tough fibre, it will be necessary to freeze the skin, with a little 
bag of ice and salt, or by means of ether or rhigolene spray, 
before operating. Bleeding may be checked at once by the 
application of absorbent cotton with pressure. Successive 
patches of a square inch, more or less, may be operated on 
daily, until the entire surface has been covered. When the 
wounds are healed, which will be very soon, the operation 
can be repeated on any patches that may have escaped. 
Scarification thus accomplished leaves little scar, and gives 
more satisfactory results than any other treatment. 

Lupus Exedens, a name given in former times to a 
rapidly eroding, ulcerative disease of the face, usually in- 
filtrating epithelioma, rodent ulcer or syphilis. (See Epithe- 
lioma, Ulcer rodent, Syphilis of the skin — ulcerative), rarely 
true lupus. 

Lupus Vulgaris (vi). Lupus vulgaris is a cellular new 

growth, characterized by variously-sized and shaped, reddish 

or brownish patches, consisting of papules, tubercles or flat 

infiltrations, usually terminating in ulceration and cicatrices. 

1 3 



186 DISEASES OF THE SKIN. 

The disease varies in appearance in different cases, and also 
according to the locality attacked and the stage of its de- 
velopment. It usually begins by the formation of small, yel- 
lowish-red or brown points under the skin, which increase in 
size, coalesce and form irregularly-shaped, roundish or ser- 
piginous, ill-defined patches of various size. The points 
referred to enlarge until they form papules, and finally tuber- 
cles. It is at this stage that the disease usually comes under 
notice. The lesions are of all sizes, from a pin's head to a 
split pea, are brownish- or yellowish-red in color, and are 
covered with a thin layer of imperfectly-formed epidermis. 
They are firm or soft, and are painless. At this stage of 
development the disease may retrograde and terminate in 
absorption of the lesions, leaving a thin, desquamative, 
cicatricial tissue, or it may go on to ulceration and complete 
destruction of the infiltrated skin, resulting in much dis- 
figurement. In its earlier stages lupus vulgaris is rarely at- 
tended with any subjective symptoms, but later there is some- 
times pain. The commonest seat of the disease is about the 
face, especially the nose, cheeks and ears. It frequently 
attacks the extremities, especially the fingers, where it may 
result in serious deformity. The limbs and trunk may also 
be involved. Lupus vulgaris is a destructive disease, often 
resulting in serious disfigurement. It spares none of the ex- 
ternal tissues, and may invade the mouth, cartilages of the 
nose, ear, larynx, and even the eye. 

The disease usually originates in childhood. It is never con- 
genital. It is rarely, if ever, hereditary. It is much commoner 
on the continent of Europe than in Great Britain, and is very 
rare among natives of the United States. I do not remember 
to have met with a lupus patient who was born in this country, 
though I cannot say that it never attacks the native American. 
It is a disease of the lower classes, not commonly attacking 
the well-nourished, but usually the debilitated and ill-fed. 



LUPUS VULGARIS. 187 

The diagnosis of lupus vulgaris from syphilis, the disease 
with which it is most likely to be confounded, is chiefly to 
be made by the history of the case in question. In addition, 
the ulcers of lupus are comparatively superficial ; those of 
syphilis ordinarily deep, and often have an excavated ap- 
pearance. The ulcer of lupus is commonly less extensive 
than that of syphilis. In lupus there are, as a rule, a number 
of points of ulceration which tend to become confluent ; 
whereas, the ulcers of syphilis usually remain distinct. The 
border of the syphilitic ulcer is sharply defined ; that of lupus 
is not apt to be so. The secretion of the syphilitic ulcer is 
apt to be copious and offensive ; that of lupus is scanty and 
inodorous. The crusts of lupus are thin and brownish ; 
those of syphilis are bulky and frequently have a greenish 
tinge. Lupus is slow in its course ; syphilis is rapid. A 
syphilitic ulcer may form in five or six weeks, while it would 
take as many years for the lupus disease to give rise to so 
much destruction. The scar of lupus is distorted ; hard, 
shrunken and yellowish. That of syphilis is whitish, smooth, 
thin, often surprisingly slight, considering the destructive 
process which has gone before. A history of other syphilitic 
symptoms is sometimes, though by no means always, to be 
obtained in syphilitic ulcer, and too much stress must not be 
laid on the absence of this. 

Lupus may be confounded with epithelioma. Though the 
diseases may occur together, yet such occurrence is rare. 
The localization of epithelioma, with its usually painful 
character, and the circumscribed induration of the lesion, 
will usually serve for the diagnosis. The ulceration of epi- 
thelioma generally starts from one point and spreads peri- 
pherally, while the ulceration of lupus usually begins at many 
points within the patch. Epithelioma very seldom occurs in 
the young ; lupus begins in childhood. 

Lupus vulgaris is to be distinguished from L. erythematosus 



188 DISEASES OF THE SKIN. 

by the occurrence of ulceration, which never takes place in 
the latter. The patches in L. erythematosus are superficial, 
uniformly reddish in color, and are covered with adherent, 
grayish scales. They are, moreover, circumscribed, and are 
without papules or tubercles. The sebaceous glands and fol- 
licles are generally markedly involved in L. erythematosus; 
in L. vulgaris they remain unaffected. 

Acne rosacea at times bears some resemblance to lupus vul- 
garis, but may readily be distinguished by its dilated vessels, 
color, the presence of acne pustules, its history and its course. 

Lupus vulgaris appears to be somewhat more amenable to 
internal treatment in this country than abroad. It is, how- 
ever, one of the most obstinate of all cutaneous diseases. 
Hygienic treatment is of great importance. Cod-liver oil is 
the most efficient internal remedy, and, next to this, iodide 
of potassium. It may be given with the oil, as may also 
iodine and phosphorus. Internal remedies should usually 
be well tried before external applications are made, as they 
alone sometimes suffice to obtain a cure. The external reme- 
dies used in the treatment of lupus vulgaris are of a mechan- 
ical nature, or comprise the various caustics. They should 
be selected with a view to the extent, locality and character 
of the lesions in any given case. In the earlier stages stimu- 
lating applications may be employed, with a view to bring 
about absorption ; equal parts of tincture of iodine and 
glycerine, painted over the part, mercurial plaster, tar and 
ointment of the red iodide of mercury may be used for this 
purpose. I must confess, however, that in my hands these 
milder remedies have usually failed of success, and I have 
always, sooner or later, had recourse to more severe measures 
before a cure could be obtained. Of true caustics, potassa, 
nitrate of silver, arsenic, carbolic acid, acetate of zinc, chloride 
of zinc and pyrogallic acid maybe mentioned. The first and 
last of these I believe to be most efficient. 



LUPUS VULGARIS. 189 

Caustic potassa should be used when thorough and exten- 
sive destruction of tissue is desired. It should be remembered 
that the effect of this caustic goes somewhat beyond the point 
touched. Dilute acetic acid or vinegar should always be kept 
at hand to limit and check the spread of the caustic and to 
neutralize it. The pain is severe for the moment, but ceases 
on the application of the acetic acid or vinegar. Nitrate of 
silver is efficient in some cases, and does not leave scars. 
Papules and tubercles may be destroyed by boring into them 
with the solid stick, while patches are most successfully treated 
by the saturated solution repeatedly applied with the charpie 
brush. Nitrate of silver is one of the best caustics to use in 
operations on lupus about the face, but it does not penetrate 
deeply. 

Pyrogallic acid, in the form of ointment, one drachm to 
the ounce, applied thickly spread upon cloths, and renewed 
twice daily, is painless and efficient in many cases. It selects 
the diseased tissue and acts but little, or not at all, on the 
healthy. Chloride of zinc is used according to the following 
formula: — 

]&. Zinci Chloridi, 

Antimonii Terchloridi.. aa... ^ij 
Acidi Hydrochlorici q. s. M. 

Enough acid is added to dissolve the chloride of zinc, 
and the mixture rubbed up in a mortar with enough powdered 
liquorice to make a paste. This is spread upon a cloth and 
applied while moist. It is a powerful caustic, very painful, 
and eats through healthy and diseased tissue alike. It has 
the high sanction of Hebra, but I have never found occasion 
to use it. 

Erasion, or scraping by means of the curette or scraping 
spoon, is useful in many cases, and is a plan of treatment 
I can highly recommend from experience. The instruments 
are cup-shaped, of steel, with sharp edges, and fastened by a 



190 DISEASES OF THE SKIN. 

short shank to a convenient handle. In size, they vary from 
a split pea to half the size of a teaspoon. The part to be 
operated upon is first frozen by means of a hand-ball atomizer, 
charged with ether or "rhigolene," or by the application of 
a gauze bag filled with powdered ice and salt, and the dis- 
eased tissue is scraped or dug out. If any of the diseased 
tissue is left, a recurrence of the lupus must be looked for ; 
the operation, therefore, must be thorough. Scraping may 
often be appropriately supplemented by the application of 
caustics, as pyrogallic acid, caustic potassa, or even the actual 
or galvano-cautery. One of the best forms of treatment is 
by linear scarification, as described under L. erythematosus. 
Squire has devised a multiple-bladed knife, by which this 
operation, over large surfaces, is much facilitated. Besnier 
highly recommends the thermo-cautery, with appropriately- 
shaped knives. The apparatus is rather complicated. 

The prognosis of lupus vulgaris will depend upon the form 
of the disease, its duration, the age of the patient, and the 
extent of surface involved. The disease, in any case, is very 
stubborn, and runs a chronic course. If it be confined to 
one patch or region, a more favorable termination can be 
looked for. The disease usually results in marked scarring 
and deformity. 

Maculae Atrophica^. (See Atrophy of the skin.*) 

Malignant Papillary Dermatitis. (See Paget' 's dis- 
ease.) 

Malignant Pustule (ii) is due to the inoculation of a 
peculiar, virulent poison, generated in cattle suffering from a 
disorder known by the name of murrain or charbon. The 
hands are usually inoculated first, in persons engaged in 
dealing with cattle and hides, and after an incubation of 
only a few hours, pain, burning and itching are experienced 
at the point inoculated, followed by the formation of a vesicle 
or pustule, with an extensive hard areola; the pustule in- 



MILIARIA. 191 

creases to the size of a quarter-dollar, and soon breaks into 
an unhealthy discharging ulcer. The constitutional symptoms 
are usually severe ; a fatal result is not uncommon. It is 
said that the disease can be conveyed by flies. 

The treatment consists in promptly destroying the dis- 
eased patch with caustic potassa, and applying disinfectant 
poultices and washes. The patient is to be supported by 
stimulants, etc. 

Medicinal Eruptions. (See Dermatitis Medicamentosa.') 
Melanoderma. (See Chloasma.) 
Mentagra. (See Sycosis and Tinea sycosis.) 
Miliaria (ii) is an acute, inflammatory disorder of the 
sweat glands, characterized by the appearance of numerous 
pin-point and pin-head-sized papules or vesicles, attended by 
pricking, tingling and burning sensations. It may show 
itself as a papular or vesicular eruption, or both varieties 
may be present. The papular variety, known commonly as 
"prickly heat," begins with the formation of numerous, ex- 
ceedingly small, acuminated, bright red papules, occurring 
in great numbers, and usually discrete, though often crowded 
together. The lesions are apt to come suddenly, and are 
usually preceded by considerable sweating. There are often 
numerous vesicles scattered among the papules. In place of 
papules vesicles may form, minute, acuminated, whitish or 
yellowish in form, very numerous, discrete, and situated on 
a raised red base. The vesicles, with their contents, give the 
affected skin a yellowish tinge. There is apt to be a good 
deal of sweating. The seat of predilection is the trunk, but 
the head, arms and lower extremities may also be attacked. 
The vesicles run an acute course, drying up in a day or two, 
and terminating in slight desquamation. The affection may 
either come to an end in a few days, or it may continue for 
some time, new crops of vesicles coming out in succession. 
It appears suddenly, developing in a few hours. It sometimes 



192 DISEASES OF THE SKIN. 

comes and goes. At times it is slight, at other times severe. 
The tingling, pricking, burning sensations which accompany 
it are occasionally very distressing. 

The affection is brought on by excessive heat, and is apt 
to be aroused or kept up by too warm clothing, flannel under- 
wear, bandages and woolen shirts, worn next the skin through 
the summer, etc. In hot climates the disease is much more 
serious than in temperate latitudes. Children and weakly 
or debilitated adults are particularly liable to the disease. 

Miliaria is simply an inflammatory disorder of the sweat 
glands. Its tendency is toward vesiculation. No difficulty 
should arise in regard to the diagnosis of miliaria. The 
diseases most likely to be mistaken for it are eczema and 
sudamen. The symptoms of the former have been so fully 
detailed above that it is only necessary to allude to them. 
With regard to sudamen, it is to be remembered that the 
vesicles of this affection rise directly from the skin, without 
inflammatory signs. When inflammation is present the affec- 
tion is miliaria. (See Sudamen.') 

The treatment of miliaria is simple. The patient should 
be kept as cool as possible and undue perspiration avoided. 
Cool baths and sponging, the use of lead-water or black wash, 
dusting with astringent powders, and avoidance of warm 
clothing, are to be recommended. Internally, refrigerant 
diuretics, as the citrate or acetate of potassium, are of use. 
The food should be light and unstimulating ; wine and beer 
are to be avoided. 

Milium (ii). Milia are those small, roundish, whitish, 
pearly, non-inflammatory elevations which are situated in 
the skin, just beneath the epidermis, and which have their 
seat, for the most part, upon the face, although they may 
occur elsewhere upon the body. They may occur singly or 
in great numbers, and when formed may last for years with- 
out change. They give rise to no subjective sensations, and 



MOLLUSCUM EPITHELIALE. 193 

no annoyance beyond the slight disfigurement which they 
cause. The affection consists in an accumulation of sebum 
within the sebaceous gland, which, owing to the obliteration 
of the duct, is unable to escape. The treatment consists in 
opening each one of the little pearly masses, squeezing out 
the cheesy, sebaceous matter which forms its contents, and, 
if there is any tendency to return, cauterizing the sac with 
a point of nitrate of silver or a drop of tincture of iodine. 

Mole, Pigmentary (iv), sometimes called Ncevus pigmen- 
losus, may consist simply of a circumscribed deposit of pigment 
in the skin, without hypertrophy of the connective tissue ele- 
ments, or of the hairy system, or in addition to the increase 
of pigment the other elements may also be involved. Moles 
vary greatly in size and shape ; they may be as small as a pea 
or bean, or large, covering considerable surface. Sometimes 
moles are thick, soft, fatty, connective-tissue growths, and 
they may possess quite a thick growth of hair. Moles may be 
single or multiple, and may occur upon any part of the body, 
but chiefly upon the face, neck, back and trunk generally. 
Sometimes they appear along the course of nerve tracts. 
They may be congenital or acquired. The small, flat and 
smooth moles without hair, seen so commonly upon the trunk, 
are almost invariably acquired during the life of the indi- 
vidual. Having attained the size of a split pea, they do not 
often grow any larger, but remain stationary. On the other 
hand, the larger, raised, rough and hairy moles are almost 
always congenital. The only cure for moles is removal by 
the knife or with caustics. Caustic potassa or ethylate of 
sodium are good caustics for the destruction of small moles. 
Molluscum Contagiosum. (See Molluscum Epitheliale. ) 
Molluscum Epitheliale (iv), formerly called Molluscum 
contagiosum, is a disease of the epithelium, characterized by 
rounded, semi-globular or wart-like papules or tubercles, of a 
whitish or pinkish color, varying in size from a pin head to a 



194 DISEASES OF THE SKIN. 

pea. The lesion frequently looks like a drop of wax upon 
the skin, or like a pearl button, flattened on top and with a 
darkish point in the centre, representing the aperture of a 
follicle. They usually occur on the face, especially the eyelids, 
cheeks and chin. They are also met with on the neck, breast 
and genitalia. They increase in size slowly or rapidly, and are 
usually without sign of inflammation, though inflammation may 
exist at times. They eventually terminate by disintegration 
and sloughing of the mass. They give rise to no pain, itching 
or other inconvenience. (See "tumors" in frontispiece.) 

Molluscum epitheliale is liable to be confounded with 
Molluscum fibrosum, but the two may be distinguished by 
their anatomical characters. In M. epitheliale the opening 
of the follicle can usually be seen as a blackish point at the 
apex of the tumor. The lesions are superficial and rise above 
the skin. They are mostly confined to the face. The tumors 
of M. fibrosum do not show the black follicular opening ; they 
are deep and often imbedded in the skin, or even in the sub- 
cutaneous tissues. They are also found in great numbers all 
over the body, and are not confined to one or two localities. 
From warts, which they sometimes resemble, the tumors of 
M. epitheliale must be distinguished by a careful comparison 
of structure. 

Local treatment is alone required. Applications of oint- 
ment of white precipitate, or sulphur ointment, well rubbed in, 
will sometimes suffice to remove the tumors. If this fails they 
may be opened with a small knife, the contents squeezed out, 
and the bottom of the cavity cauterized with nitrate of silver. 
They may also be burned out with mild caustics, but severe 
measures should never be used, because the disease is slight 
and tends to get well spontaneously. 

Mother's Mark. (See NcevusJ) 

Molluscum Fibrosum (vi) is a connective-tissue new 
growth, characterized by sessile or pedunculated, soft or firm, 



MOLLUSCUM FIBROSUM. 195 

roundish, painless tumors, varying in size from a split pea to 
an egg, or larger, seated beneath and in the skin. 

The growths may occur singly or in great numbers, when 
they usually occupy the greater part of the body. They 
assume various shapes ; rounded and sunken in the skin itself, 
or in the subcutaneous tissue ; or in other instances, club or 
pear-shaped and pedunculated, hanging often by their elon- 
gated pedicles. In consistence they are uniformly soft, but 
between the fingers are found to have a certain amount 
of body, the larger ones having a more or less elastic feel. 
The skin covering them is nearly normal in color and 
appearance. It may be loose or stretched ; hypertrophied 
or atrophied. 

The size of the tumors varies exceedingly ; they are usually 
pea to cherry size, but may be much larger, single peduncu- 
lated ones often weighing many pounds. They are more apt 
to be found on the trunk, and may exist in great numbers, 
irregularly distributed over the surface. They are not at- 
tended by any pain, but may be annoying, from their size 
and weight, or may interfere with the movements of the 
body. They may appear at any time during life, generally 
first showing themselves in childhood, and may grow slowly, 
or rapidly at first, during life. When a certain size is reached 
they remain stationary, and do not change, except that the 
large pendulous tumors may ulcerate on the surface, from mere 
weight. Patients with this affection are apt to be stunted in 
physical and mental growth, though the general health is not 
impaired. It may be inherited, and may show itself in several 
members of the same family. 

The diagnosis is easy. From molluscum epitheliale the 
tumors are distinguished by the fact that they do not possess 
any depression or aperture on their surface, and also that they 
are found on all parts of the cutaneous surface. From neuro- 
mata they are distinguished by the absence of pain, and from 



196 DISEASES OF THE SKIN. 

lipomata by the soft and lobulated structure which those fatty 
growths possess. 

The treatment of Molluscum fibrosum is simple. Where 
the growths are large or are situated so as to give annoyance, 
they may be removed by the knife. If pedunculated, they 
may be ligated or removed by the galvano-cautery. 

The disease commonly lasts through life, although some of 
the tumors may undergo involution. The tumors either con- 
tinue to increase in size and number, or, having attained their 
growth, remain stationary. 

Morphcea (iv), in its usual form, begins by the develop- 
ment of one or more roundish or irregular hyperaemic patches, 
the size of a dime or quarter-dollar. When fully developed 
the morphceic patch resembles a plate of ivory let into the 
skin, having a lardaceous or waxy appearance, and surrounded 
by a brownish- or lilac-colored areola of fine capillary vessels. 
The lesions may develop to the size of the palm, they may 
be found in any part of the body, and having attained their 
full size, they may remain stationary for years. Sometimes 
they undergo spontaneous evolution ; at other times the skin 
shrivels, wrinkles, and a sort of atrophy and browning of all 
the tissues takes place. This condition has been named by 
some "scleroderma." It is not at all like the typical form 
of that disease, however. 

The treatment of morphcea is not usually followed by any 
satisfactory result. More good has been gained by the ad- 
ministration of arsenic, with the use of electricity, than by 
any other means. 

Nsevus (vi). (See also Telangiectasis?) Vascular naevi 
are congenital formations, composed chiefly of blood vessels 
which have their seat in the skin and subcutaneous tissues. 
They may be prominent, turgescent, erectile, or even pulsat- 
ing, tumor-like growths {angioma cavernosuni), or they may 
be flat, non-elevated, well-defined or faint, smooth patches 



NjEVUS. 197 

(ncevus simplex). The latter is the "mother's mark" of 
popular nomenclature. Naevi occur of all sizes, from that of 
a small pin-head to hand-sized or larger areas. Their color 
may be any shade of red. They are seldom multiple, and 
generally occur about the head, the lip being a favorite seat. 
They are usually stationary, but sometimes decrease as life 
advances; occasionally, on the other hand, in the erectile 
varieties, an increase in size is observed. They all become 
paler on pressure. The more prominent growths are mark- 
edly compressible. 

The treatment of naevi will depend upon the situation, 
form and size of the growth in any given case. The principle 
of treatment is either bodily removal of the growth by means 
of the knife or ligature, or the excitation of plastic, inflam- 
matory action. The latter may be accomplished in any one 
of a number of ways. Minute, pin-head-sized nsevi may be 
destroyed by puncture with a red-hot needle, or a needle 
charged with nitric or glacial acetic acid, or with a needle 
connected with the positive pole of a four to ten-cell combi- 
nation of a constant current battery. When the growth is a 
little larger — the size of a split pea to that of a ten-cent piece 
— it may be treated by caustic applications. Of these sodium 
ethylate is one of the most efficient. It rarely causes severe 
pain; but should it do so in any case, the application of a 
little chloroform will check this. It is applied on the end of 
a glass rod. Other caustics are nitric acid, glacial acetic acid 
and solution of caustic potassa. Injections with tincture of 
the chloride of iron, tincture of cantharides and other similar 
substances, as formerly practiced, are to be condemned. 
Several fatal cases have been reported where the tincture of 
iron has been employed. Vaccination has sometimes been 
practiced with success. The virus is introduced by means 
of multiple puncture with needles. This is an excellent 
method of treatment. Linear scarification has been tried 



198 DISEASES OF THE SKIN. 

without success. Punctate scarification, by means of an instru- 
ment composed of a number of fine needles, arranged in a 
bundle and charged with caustic, is recommended by some 
writers. Electrolysis, as before mentioned, may be used on 
these larger naevi. The galvano-cautery has also been suc- 
cessfully used. 

Naevus Pigmentosus. (See Mole, pigmentary.') 

Nails, Diseases of. (See Eczema, Psoriasis, Tinea cir- 
cinata, Syphilis, Onychia, etc. Also Atrophy of nail, Hyper- 
trophy of nail.) 

Neoplasm, Inflammatory Fungoid. (See Sarcoma.) 

Nettle Rash. (See Urticaria.) 

Neuralgia of the Skin. (See Hyperesthesia.) 

Neuroma Cutis (vi) is an excessively rare affection, 
characterized by the presence of variously-sized and shaped 
nerve growths, having their seat primarily in the true skin. 
The lesions are visible to the eye as split-pea-sized tubercles, 
scattered, or aggregated in large numbers over the affected 
locality. The lesions are of a rose or pink color, smooth and 
firm, and the intervening skin normal. Pain, of a paroxysmal 
character, and extremely severe, is the chief symptom. Move- 
ment of the affected part, a draught of cold air, or even mental 
•worry and excitement are often sufficient to cause pain and 
even agony. 

The affection must be distinguished from painful subcuta- 
neous tubercle, a not uncommon affection. Here the lesion 
is usually single, and is not situated in the skin, but in the 
subcutaneous tissue. 

The only treatment of neuroma cutis is the excision of a 
portion of the nerve trunk leading to the affected area. 

Neurotic Excoriations. A name given to a peculiar 
form of hagmatidrosis. (See Sweat, bloody.) 

Nipple, Eczema of. (See Eczema. See, also, Page? s 
Disease of the Nipple.) 



paget's disease of the nipple. 199 

Nits. The ova of the Pediculis capitis, and of the 
P. pubis. (See Pediculosis.} 

Noli-me Tangere. (An old name for Lupus vulgaris .) 
Odor of the Human Body. (See Bromidrosis.) 
Onychauxis. (See Hypertrophy of the nails.} 
Onychia. Inflammation of the matrix of the nail, usually 
followed by falling of the nail itself. One form of the dis- 
ease is characterized by the formation of herpetic vesicles 
under the nail, with extreme neuralgic pain. The nail may 
or may not be thrown off in this form of the disease. 

The treatment of onychia should be directed to the removal 
of any general cause in the condition of the system. Locally, 
the following ointment is of service : — 

&. Liq. Ferri Subsulphatis....... ^ss 

Ung. Aquse Rosse :§ ss. M. 

Or, when there is much pain, the following : — 
R . Hydrarg. Chlor. Mite, 
Pulv. Opii, 

Extract Belladonna aa gr. iij 

Ung. Aquae Rosae J;ss. M. 

Onychia, Syphilitic. (See Syphilis of the nail.) 
Onycho-gryphosis. (See Hypertrophy of nail.) 
Onycho-mycosis. (See Tinea circinata of the nail.) 
Pacchydermia. (See Elephantiasis.) 
Paget's Disease of the Nipple (vi), or " Malignant 
Papillary Dermatitis,' 1 is a malignant disease of the nipple 
and adjacent structures, at first closely resembling eczema, 
and later taking on the features of carcinoma. The disease 
begins as an ordinary red, weeping eczema, with symptoms of 
burning and itching. The discharge, crusts, etc., are precisely 
those of eczema, but the disease takes on a peculiar livid 
color, different from the brighter red of eczema. The nipple 
gradually "melts away" and becomes obliterated, but not 
retracted ; the affected tissues are firm, hard, rather sunken 



200 DISEASES OF THE SKIN. 

below the general level of the skin ; gradually the structure 
of the mammary gland becomes involved, and also the axil- 
lary glands. The disease makes very slow progress, but its 
tendency is fatal. The treatment is thorough destruction, by 
caustics, in the earlier stages, and in the later, amputation of 
the breast. 

Parasitic Sycosis. (See Sycosis.) 

Paronychia. An inflammation around the edge of the 
nail — a whitlow or "run around." It usually results from 
the nail taking an abnormal direction of growth and pressing 
into the soft parts. (See Onychia and Syphilis of the nail.) 

Pediculosis (ix), {Lousiness), is a contagious animal 
parasitic affection, characterized by the presence of pediculi 
or lice, and the lesions which they produce, together with 
scratch marks and excoriations, accompanied by itching. 
Three varieties of the disease are encountered, which are 
designated according to the names of the species of lice, 
viz., pediculosis capitis, pediculosis corporis and pediculosis 
pubis, or head, body and crab lice. (See below, under these 
titles.) 

Pediculosis always occurs as the result of contagion ; a 
spontaneous origin of the parasites is quite incredible. The 
pediculi do not bite, but are furnished with a sucking appara- 
tus, which they insert into the mouth of a follicle, and obtain 
blood by the means of this. 

The diagnosis of pediculosis may almost always be made 
by finding the parasites, but these are frequently few in num- 
ber in any given case, and must be carefully searched for, 
remembering in the case of each variety its especial habitat. 
When the pediculi cannot be found, the location of the scratch 
marks offers valuable circumstantial evidence pointing to the 
parasitic character of the disease. In the scalp and pubis 
the presence of nits or ova may almost always be made out, 
and they, of course, are pathognomonic. The prognosis of 



PEDICULOSIS CAPITIS. 201 

pediculosis is always favorable, and when the directions are 
carried out faithfully a speedy cure may be expected. 

Pediculosis Capitis is due to the presence of the pedi 'cuius 
capitis or head louse. The parasite is found on the scalp alone, 
the occipital region being the favorite seat. The lice are 
sometimes found in the scalp and sometimes on the hairs. 
The ova, or "nits," small, whitish, pear-shaped bodies, glued 
to the hairs by the smaller end, some distance from the scalp, 
resemble scales of epidermis. Lice are usually met with 
among women and children of the poorer class, though they 
are sometimes found on persons of refinement. I have several 
times encountered them on ladies, where they appeared to 
have been contracted in sleeping cars while traveling. The 
parasites attack the scalp and give rise to considerable irrita- 
tion, itching and consequent scratching. Effusion of serum, 
pus and blood results from this, and the hairs become matted 
together in a crust. Lice, as a rule, cause more mischief in 
those who are poorly nourished and ill-cared-for. The ma- 
jority of cases of eczema in the back of the head, in the 
poorer class of children, are caused by lice. When the 
affection has existed for some time there is a disgusting odor 
about the scalp ; the patient loses sleep from the itching ; the 
mind becomes harassed, and the general health may be more 
or less impaired. 

The best treatment for head lice is to saturate the scalp 
nightly, for several successive times, with kerosene, care being 
taken not to allow the oil to trickle down over the face 
and neck, for fear of its causing excoriations. A night-cap 
is to be used, and the head washed with castile soap and 
warm water in the morning. When kerosene cannot be 
used, the next best thing is the tincture of cocculus indicus. 
Where, owing to shortness of hair and the presence of eczema, 
ointments can be employed conveniently and profitably, that 
of ammoniated mercury, in the strength of twenty to sixty 
14 



202 DISEASES OF THE SKIN. 

grains to the ounce, will be found useful. An ointment of 
one drachm of powdered stavesacre seeds to the ounce of 
lard is also a good remedy. The nits, which are, however, 
usually killed by the applications of kerosene, are to be 
removed by repeated washings with soda or borax washes, 
soft soap, vinegar, dilute acetic acid or alcohol. It is seldom 
or never necessary to cut the hair. In children it is often 
more convenient to do so, but in adults it is an unnecessary 
sacrifice, which may be avoided by patience in relieving the 
hair of pediculi and nits. The head coverings should be 
destroyed or thoroughly disinfected by baking or boiling. 

Pediculosis Corporis, or lousiness of the body, is pro- 
duced by the pediculis corporis, body, or more properly, 
clothes louse, which lives in the garments, and thence makes 
predatory excursions upon the skin. It is very similar to the 
head louse, but is considerably larger. Body lice are apt to 
be found along the seams of the clothing, particularly where 
this comes in closest contact with the skin, as about the neck, 
shoulders, waist and buttocks. As they move over the sur- 
face or attack the skin, they give rise to intensely disagreeable, 
itching sensations. As the parasites multiply, the itching 
becomes so violent, that the distress is almost unendurable ; 
the scratching is generally severe, and long and streaked or 
short and jagged scratch-marks, with blood crusts and pig- 
mentation, are characteristic features of the disease. On 
close inspection, the primary lesions, which are minute, red- 
dish puncta, with slight areolae, may be seen marking the 
points at which the parasite has drawn blood. 

The chief seats of the lesions are the back, especially about 
the scapular region, the chest, abdomen, hips and thighs. 
When the affection has lasted for months and years general 
pigmentation may occur, as the result of long-continued irrita- 
tion and scratching. Children are very seldom attacked. 
The disease is one of want, poverty and neglect. It some- 



PEDICULOSIS PUBIS. 203 

times occurs among a better class of people, particularly in 
the aged ; but even here it will be found to have been brought 
about by want of personal care. 

To get rid of body lice, a hot bath, with soap, should be 
taken while the clothing is being heated in an oven or boiled, 
to destroy the parasites with their ova. After the bath, 
inunctions are to be practiced with an ointment of powdered 
stavesacre seeds, two drachms to the ounce, digested in hot 
lard and strained. A lotion of carbolic acid is useful to allay 
the itching : — 

R. Acidi Carbolici spij 

Glycerinae f 25 j 

Aquae Oj. M. 

The disinfection of clothing should be carefully carried 
out, and must be repeated again after a few days, if it has 
not been entirely successful. 

Pediculosis Pubis. The pediculus pubis, or crab louse, 
though usually found on the pubis, is also encountered in the 
axillae, sternal region and beard, in the male, eyebrows and 
even eyelashes. Crab lice are found either crawling about 
the hairs or adhering closely to the surface of the skin ; their 
strong claws permit them to take such hold of the hairs that 
they are often detached only with difficulty. The ova are 
very much like those of the pediculus capitis, and are found 
firmly attached to the hairs. 

They infest adults chiefly, and give rise to the same symp- 
toms as the other pediculi. Although almost always con- 
tracted in sexual intercourse, yet they now and then find 
their way to the pubis of persons who are entirely unable to 
account for their presence. The amount of irritation caused 
by their presence varies with the individual ; it is, as a general 
thing, comparatively slight. 

Crab lice may be removed by the application of tincture of 
cocculus indicus, of full strength or diluted, or by any of the 



204 DISEASES OF THE SKIN. 

ointments or lotions used in the other forms of pediculosis. 
Mercurial ointment, the well known popular remedy, is no 
more effectual than the others, and makes a nasty mess. Its 
use, in general, is to be avoided, in favor of any of the other 
applications. When patients will permit, shaving the pubis 
shortens the cure greatly. 

Peliosis Rheumatica. (See Purpura.) 

Pellagra. A disease occurring chiefly in Italy and some 
parts of eastern Europe, and supposed to be induced by eat- 
ing spoiled corn, by malaria, etc. It is characterized by a 
chronic inflammation of the skin, of an erythematous char- 
acter, accompanied by violent burning sensations and occa- 
sionally runs to blisters. It occurs chiefly on parts exposed 
to the sun, exposure to which is said to be the immediate 
exciting cause. The patient becomes debilitated, feverish, 
loses weight, and displays various nervous symptoms, as 
vertigo, delirium, etc. The disease has not been met with in 
this country as yet, but the increasing Italian immigration 
makes it likely enough to turn up sooner or later. The 
treatment is to be directed against the general symptoms and 
condition of the patient. 

Pemphigus (ii). Pemphigus is an acute or chronic 
inflammatory disease, characterized by the formation of a 
succession of irregularly-shaped blebs, varying in size from 
that of a pea to an egg. (See " blebs," frontispiece.) 
There are two varieties, P. vulgaris and P. foliaceus. In 
pemphigus vulgaris the disease may attack any part of the 
body, but is common upon the limbs. It may also attack 
the mucous membrane of the mouth and vagina. The lesions 
are blebs, from beginning to end, forming slowly or some- 
times rapidly, in the course of a day. They may be few in 
number or quite numerous, and often vary greatly in size in 
the same case. They are tensely stretched, like bladders of 
liquid, and rise directly from the level of the skin, which is not 



PEMPHIGUS. 205 

usually reddened. They are clear at first, with serous con- 
tents, but later are opaque, containing pus. They do not 
rupture spontaneously, but gradually dry up, each bleb lasting 
one to three or six days. The lesions are apt to come in 
crops ) they do not burn or itch to any marked degree. 
In adults there is little or no disturbance of the general 
system. In children the disease is apt to be accompanied 
by feverishness. 

In pemphigus foliaceus the blebs are flaccid and only partly 
filled with fluid, which seems rather to undermine the epider- 
mis than to lift it into blebs. The lesions often coalesce, 
involving a large part of the surface ; fresh lesions are con- 
tinually forming ; the fluid dries into thin, whitish flakes, 
which are cast off, leaving an excoriated, red surface, and 
presenting the appearance of a superficial scald. The disease 
may last for years and the patient finally succumb to 
exhaustion. 

True pemphigus is a rare disease in this country ; only 
89 cases are reported in the 58,617 cases of skin disease 
observed by the members of the American Dermatological 
Association. It is more common in children than in adults. 
Poor food and bad hygiene, pregnancy and menstrual dis- 
orders, mental depression, general debility and prostration, 
are among the causes. The disease is not contagious. 

The diagnosis of pemphigus is usually not difficult. The 
presence of blebs does not necessarily indicate pemphigus, 
as these are developed in other diseases and by artificial 
means. (See Dermatitis medicamentosa.) So-called " pem- 
phigoid" eruptions, obscure in origin and nature, are some- 
times met with, but their course is not that of pemphigus, 
properly so-called. (See Dermatitis herpetiformis.) Pem- 
phigus is not under any circumstances to be confounded with 
the bullous syphiloderm, formerly called " pemphigus syphi- 
liticus." The latter is a purulent bleb, drying up into a 



206 DISEASES OF THE SKIN. 

thick crust, with a deep ulcer underneath. Erythema multi- 
forme, in the bullous form, and impetigo contagiosa, are 
occasionally mistaken for pemphigus. A reference to these 
diseases under their respective titles will show their charac- 
teristic points. 

The internal treatment of pemphigus is that which is most 
important. The general history and circumstances of the 
case must be looked into, and any defects of constitution or 
circumstance remedied. Among drugs, arsenic is most potent. 
Fowler's solution, in doses of four minims, thrice daily at 
first, rising gradually to the limit of tolerance, may be given. 
Wine of iron is the best excipient for Fowler's solution in 
these cases. Arsenic produces its effects slowly, and it should 
be persisted in for months, if necessary, without expecting a 
cure or even amelioration, in so chronic a disease. Quinine 
is of value, and in some cases linseed meal, in ounce doses, 
with milk, has proved valuable. Cod-liver oil and stimulants 
may be required at times. The patient should be allowed to 
rest, and should be free from worry and anxiety, so far as this 
is practicable. 

Local treatment is also important. The blebs should be 
punctured and evacuated as soon as they have formed. 
Soothing and astringent lotions, and especially dusting pow- 
ders, as that composed of equal parts of oxide of zinc and 
starch, may be employed. Baths containing bran, starch or 
gelatine, may be employed in some Cases. The continuous 
bath, in which the patient lives, eats and sleeps, for months, 
has been employed in severe cases. Occasionally, water does 
not agree, and in these cases mild ointments, as that of oxide 
of zinc or diachylon, may be prescribed. 

Pemphigus runs an extremely uncertain course. Relapses 
frequently occur. When the blebs are numerous, flaccid, 
imperfectly formed, and inclined to rupture, and when they 
are rapidly and frequently formed, the prognosis is unfavor- 



PITYRIASIS SIMPLEX. 207 

able. Repeated febrile attacks also indicate an unfavorable 
tendency. On the whole, then, we may say that the prognosis 
of pemphigus must be very guarded, as even when beginning 
as a slight attack, an unfavorable turn may be taken and the 
case end fatally. 

Pemphigus, Syphiliticus, properly the bullous syphilo- 
derm. (See Syphilis of the skin.) 

Peforating Ulcer of the Foot is usually characterized 
by a small aperture, like the orifice of a sinus, in the centre of 
a large corn, which leads directly down by a narrow channel 
to exposed and diseased bone. Sometimes there are granu- 
lations around the orifice. The lesion is indolent, there is 
no pain, even on pressure, and little or no discharge. The 
ulcer is usually seated over the articulation of the metatarsal 
bone with the phalanx, generally over that of the first or the 
last toe. There may be several ulcers, and both feet may be 
affected. It is supposed to be due to nerve influence. Com- 
plete rest, even by the use of an artificial limb, is sometimes 
necessary to heal this rebellious disease. 

Petechias are the small red spots, quickly changing to blue 
and livid tints, which characterize the eruption of purpura. 
(See Purpura.} 

Phosphorescent Sweat. Cases of this peculiar condi- 
tion have been reported as occurring in phthisis and after 
eating phosphorescent fish, as well as in cases of excessive 
sweating, the perspiration appearing luminous in the dark. 

Phthiriasis. (See Pediculosis.) 

Piebald Skin. (See Vitiligo.) 

Pigmentary Mole and Nsevus. (See Mole.) 

Pityriasis Simplex (Capitis) (ii). A scaly disease of the 
skin, chiefly occurring in the scalp, where it forms the com- 
monest variety of "dandruff." Fine pearly scales form in 
more or less abundance through the scalp and are brushed off 
or drop on the neck and shoulders. There is some itching. 



208 DISEASES OF THE SKIN. 

After a time, in young persons, the hair begins to fall and early 
baldness results. (See Alopecia?) Pityriasis of the scalp 
may be confounded with squamous eczema, psoriasis and 
some forms of seborrhcea, into which latter disease it some- 
times merges. In eczema, however, the scalp is redder and 
more infiltrated, the scales are more scanty, and there is 
almost always either a history of weeping and oozing, or some 
characteristic lesions of eczema elsewhere. In psoriasis the 
scales are apt to have a yellowish tinge ; the disease prevails 
more around the edge of the hairy scalp, and some charac- 
teristic patch of psoriasis is almost always to be seen elsewhere 
on the skin. In seborrhcea the oily element is prominent ; 
the scales are matted together, yellowish and greasy, so that 
if they are laid on blotting paper a grease spot soon forms. 

'I he treatment of pityriasis of the scalp is chiefly local. 
The scalp should be thoroughly cleansed by shampooing with 
soap and water, or if the scales are abundant, with the spiritus 
saponis kalinus : — 

R. Saponis Viridis ^ij 

Alcoholis ^j. M. 

Dissolve by the aid of heat and filter. 

This soapy wash is to be mixed with water and used as a 
shampoo. A teaspoonful with an equal quantity of water 
rubbed into the scalp, with the addition of more warm water, 
will quickly work up into a fine lather that will cleanse the 
scalp effectually. So soon as this is washed out with pure 
water and the scalp dried, one of the following applications 
should be made. If the hair is thick, the following is prefer- 
able : — 

R. Acid Carbolic '. ^j 

Alcoholis seu Aq. Cologniensis ^iss 

Glycerini £iiss 

Ol. Limonis ^iss. M. 

A few drops of this mixture are dropped here and there over 



PITYRIASIS SIMPLEX. 209 

the surface by means of a Barnes' dropper, such as is used 
for eye drops, and then well rubbed into the scalp with a stiff 
brush. As little as possible should be allowed to get into the 
hair, as it is easily made greasy by repeated applications. 
This and all applications, except the soapy wash, should be 
made daily, at least at first. The spiritus saponis kalinus 
may be used every two days or every week, as may be neces- 
sary to keep down the accumulation of scales and the matting 
of hair by the oily applications. 

When the hair is thin and short, ointments may be used, 
and the best of these, for ordinary use, is one containing 

sulphur : — 

R. Sulphur Praecipitat 3J-ij 

Ung. Petrolii |j M. 

Another ointment, very useful in these cases, is the 
following : — 

R. Acidi Tannici ^j 

Ung. Aquae Rosae, 

Ung. Petrolii aa ^iv. M. 

A certain number of cases do well under stimulant mercu- 
rial remedies, as this: — 

J&. Hydrarg. Ammoniat ^j 

Ung. Petrolii ^j. M. 

Now and then, but very rarely, tar is of use. Its odor and 
stickiness is, however, a serious objection to its use. The 
following formula will be found as convenient as any : — 
R . 01. Cadini, 

Ol. Amygdalae aa £j 

Aq. Cologniensis 3yj. M. 

Internal treatment is sometimes, but not by any means 
always, demanded. Tonics, and particularly iron, will be 
found useful. If there is constipation, with a tendency to 
anaemia, a not very uncommon combination in young persons 
suffering from pityriasis, the ?nistura ferri acida will be found 
an efficient tonic aperient : — 



210 DISEASES OF THE SKIN. 

R. Magnesii Sulphat ^j 

Ferri Sulphat gr. iv 

Sodii Chloridi t ^ss 

Acidi Sulphurici, dil f^ij 

Infus. Quassise ad f ^ iv. M. 

SlG. — A tablespoonful in a tumbler of water, before breakfast. 

The amount of the dose must be regulated by the effect 
produced in each individual case. 

When an iron tonic alone is required, the following may 
be given : — 

R. Tinct. Ferri Chlor., 

Acid. Phosphoric, dil... .aa.... i% ss 

Syrupi Limonis f^j. M. 

Sig. — Teaspoonful, or less, in a wineglass of water, thrice daily. 

Pills of the iodide of iron are also useful in some cases. 

The prognosis of pityriasis capitis, in itself considered, is 
favorable, although some time may be necessary to effect a 
cure. Taken in hand early, before the hair has fallen much, 
the defluvium capilloru?n may be arrested. Little more can 
be hoped for than this, in the more favorable cases, and when 
"dandruff," with progressive baldness, has existed for some 
time, the hair cannot be made to grow again by any drug at 
present known. 

Pityriasis Rosea (ii), also called '•' Pityriasis maculata 
et circinata," is an affection so slight as hardly to be worth 
mentioning, were it not that it is frequently mistaken for 
more important affections. It is characterized by discrete or 
confluent, macular or maculo-papular lesions, from a pin-head 
to half-dollar size, slightly or not at all raised. The color of 
the lesions is rosy or pale red, with a more or less tawny or 
green tint. The surface is always dry and slightly scaly, arid 
there is a tendency to heal in the centre, giving a circinate 
appearance. The seats of election are the sub-clavicular, 
lateral thoracic, and scapular regions. The disease generally 



PITYRIASIS RUBRA. 211 

lasts from one to three months. It may be mistaken for 
syphilis, tinea versicolor, tinea circinata, seborrhcea corporis, 
lichen ruber and psoriasis, more especially the three first 
named, some forms of which it closely resembles. Refer- 
ence may be made to these affections, to ascertain their 
characteristics. The affection, though strongly suspected 
of being parasitic, has never been proved such. It is not 
contagious. Treatment does not seem to influence the 
disease, which, however, gives no trouble or annoyance, 
though often causing mental disquietude. 

Pityriasis Pilaris. (See Keratosis pilaris.) 
Pityriasis Rubra is an inflammatory disease, involving 
usually the whole surface, characterized by red coloration 
and abundant and continuous exfoliation of epidermis in the 
form of large, thin, whitish scales. Beginning in one or 
more spots, the disease spreads rapidly, and in a short time 
may invade the entire surface, which is uniformly reddened 
and covered with whitish or grayish scales, which are being 
continually cast off and re-formed. The skin, as a rule, is 
not at all thickened ; usually there is little or no burning or 
itching. The patients are very susceptible to the sensation 
of cold. The affection is usually chronic, and it may last 
for years. Pityriasis rubra is a disease of adult life, and is 
very rare, only sixteen authentic cases having been reported 
among nearly sixty thousand cases of skin diseases observed 
by the members of the American Dermatological Associa- 
tion during the past five years. Its interest lies in the fact 
that it may readily be mistaken for other important dis- 
eases, as eczema squamosum, psoriasis, lichen ruber and 
pemphigus foliaceus. It differs, however, from eczema in 
its universal distribution, absence of marked thickening of 
the skin, size of scales and their rapid production and abund- 
ance, and in the absence of burning and itching. Psoriasis 
rarely invades the whole, or even the greater portion of the 



212 DISEASES OF THE SKIN. 

surface, while pityriasis rubra, as a rule, attacks the whole 
surface uniformly. The scales in psoriasis are thicker and 
yellowish, the patches markedly infiltrated, and where the 
process is active there is itching and burning. From pem- 
phigus foliaceus, pityriasis rubra differs in showing no dispo- 
sition to the formation of bullae. (See, also, under these 
various diseases.) 

Treatment must be on general principles and adapted to 
the needs of each case. Locally, bran and other soothing 
baths, and inunctions with bland and soothing ointments, 
are often available. Saline aperients, diuretics, iron, quinine 
and arsenic may be prescribed, but, in general, time seems 
to do more than treatment. 

Pityriasis Versicolor. (See Tinea versicolor.') 
Plica Polonica is not a disease in itself, but is, practically, 
aggravated lousiness. It was formerly common in Poland and 
Austria, and occurred chiefly among the low and filthy in- 
habitants of that part of Europe. It consists in a matted and 
tangled condition of the long and neglected hair, glued 
together by discharges from the scalp irritated by lice. It is 
unknown in this country, because it requires a lifetime of 
assiduous cultivation of dirt and neglect to produce it. I 
have heard patients express the fear that they were victims of 
this disease, and have even heard the diagnosis made by phy- 
sicians, but I venture to say that no case of true plica Polonica 
has ever occurred in this soap-and-water-ridden country, since 
the arrival of the settlers at Jamestown. 

The treatment is simple in the cases of pediculosis capitis 
which are severe enough to be sometimes called by this name. 
The hair is to be cut short, if really necessary, parasiticide 
remedies applied (see Pediculosis capitis), and cleanliness 
enjoined. 

Pompholyx. (See Dysidrosis.) 

Porcupine Disease. (See Ichthyosis hystrix.) 



PRURIGO. 213 

Porrigo. (See Ecze?na of the head.) P. decalvans (see 
Alopecia areata). P. favosa (see Favus). 

Port-Wine Marks. (See Ncevus.) 

Prickly Heat. (See Miliaria?) 

Prurigo (ii). An excessively rare disease in this country, 
though met with in Europe. It usually begins at an early 
age, within the first or second year, in the form of an urticaria, 
and commonly lasts through life. When developed it consists 
of firm, pin-head- to pea-sized elevations under and in the 
skin, usually discrete, but sometimes grouped. The color of 
the lesions is pale red, or, like the surrounding skin, there 
are no scales. The disease usually first attacks the extensor 
surface of the lower extremities, particularly the tibiae. The 
forearms are next invaded, and then the trunk. The head is 
rarely attacked ; the palms and soles never. In severe cases 
buboes may form in the glands of the inguinal regions. 

The eruption is accompanied by intense itching, and con- 
sequently blood crusts are always present, and in time the 
hairs are- torn and rubbed off, and the skin becomes harsh, 
thickened and pigmented. 

The life of the patient is one of untold misery, far sur- 
passing, according to the accounts of European physicians, 
that to which any other disease gives rise, and suicide is the 
occasional recourse of the unfortunate victim. 

The diagnosis of prurigo is not difficult, although cases 
of eczema are occasionally reported in the journals under 
this name, usually by physicians not conversant with skin dis- 
eases. The disease has a distinct and well-defined history, 
which prevents it from being mistaken for eczema. Eczema, 
indeed, often accompanies prurigo, being aroused by scratch- 
ing or the application of remedies, but this can be cured by 
appropriate treatment, while the prurigo goes on, unaffected 
by treatment. Pruritus and pediculosis corporis used to be 
called prurigo, but the common consent of writers on skin 



214 DISEASES OF THE SKIN. 

diseases for the past fifteen years has confined the designa- 
tion to the disease just described. There is no symptom but 
that of itching in common between these affections, and 
reference to the titles Pruritus and Pediculosis corporis, in 
this work, will show how different are the symptoms. 

The treatment of prurigo, should a genuine case present 
itself (only 6 have been reported in the 58,000 cases of skin 
disease included in the statistics of the American Dermato- 
logical Association !), should be first directed to the general 
condition of the patient. The diet should be generous. 
Everything that will tend to improve the state of the patient's 
health is to be taken into consideration. Iron, arsenic, 
quinine, and especially cod-liver oil, may be prescribed. 
External remedies are particularly useful. Baths of various 
kinds, and also tar and sulphur applications, are particularly 
to be mentioned. 

The prognosis of prurigo is not very hopeful. It is said 
to be curable if treatment is commenced in childhood, but 
scarcely so in the adult. If a case is reported as having been 
easily cured, it is probably because a mistake has been made 
in diagnosis. 

Prurigo Senilis. (See Pruritus and Pediculosis corporis.*) 
The name prurigo was formerly given to the diseases now 
known by these names. 

Pruritus (viii). Pruritus is a functional, cutaneous affec- 
tion, manifesting itself solely by the presence of the sensation 
of itching, without structural alteration of the skin. The 
various forms of itching encountered in the course of many 
diseases of the skin, accompanied by organic changes, have 
been mentioned elsewhere, in connection with the diseases in 
which they occur. Pruritus, it must be remembered, is a 
distinct affection. The first thing that occurs is itching, and 
any lesion of the skin visible later is the result of the scratch- 
ing to which this symptom gives rise. The feeling varies in 



PRURITUS. 215 

different cases. Sometimes the patient describes it as being 
as if a piece of rough flannel were in contact with the skin. 
At other times it is said to be like the crawling of insects, 
or like a tingling sensation with the desire to scratch. It 
may be slight, or so severe as to be almost intolerable. It is 
most frequent in middle life and old age (the latter is one 
variety of the " prurigo senilis" of old writers, the other is 
lousiness). 

The itching arouses an irresistible desire to scratch and 
rub, with the result that the surface is generally seen to be some- 
what roughened, hyperaemic and excoriated, in a slight or 
marked degree. In other cases the external signs are slight, 
so that were it not for the statement of the patient, the pres- 
ence of any marked disorder might be doubted. The itching 
is usually intermittent, and is always worse at night. Pruritus 
rarely invades the whole body at one time, though various 
regions may in turn be attacked. In most cases it occurs in 
certain localities, and chiefly the trunk, scalp, genitalia and 
anus. 

Pruritus vulvce must not be confounded with other itching 
affections of the female genitals. The itching may be seated 
in the labia, vagina or clitoris, and is an exceedingly dis- 
tressing affection. It is more apt to occur in middle or old 
age. In children, it is often caused by the presence of 
ascarides in the rectum and about the anus. 

Pruritus scroti is the form generally met with in the male. 
It may involve this region alone, or may extend along the 
perineum to the anus. The orifice of the urethra may also 
be the seat of the disease. The sensations are usually in- 
tensely annoying, and cause the patient to rub and scratch 
violently. It is worse at night, and is aggravated by warmth. 

Pruritus ani occurs in both sexes, and in children as well 
as adults. The itching may be around the orifice or just 
within the rectum. In middle-aged or elderly persons, it is 



216 DISEASES OF THE SKIN. 

very often associated with hemorrhoids. It is, if possible, 
more intolerable than any other of the local varieties. Some- 
times it is constant, but more often it comes and goes from 
time to time, and is also worse at night. 

The causes of pruritus are extremely varied, and it is 
important to keep this in mind, for the cause must, in most 
cases, be removed, in order to obtain a cure. It may be 
caused by physiological changes, as gestation, or by any 
irregularity of the menstrual function in young women. 
Occasionally, it is associated with hysteria, and it is some- 
times met with at the climacteric period. Leucorrhcea is a 
common cause. Organic diseases of the uterus and ovaries 
are, at times, accompanied by it. Pruritus is likewise met 
with in many cases of jaundice, and is sometimes a distressing 
symptom. Various diseases of the nervous system are accom- 
panied by pruritus. Gastro-intestinal derangement, consti- 
pation, genito-urinary diseases, in both sexes, and, finally, the 
ingestion of certain medicines, and notably of opium, may 
give rise to the affection. It would hardly be necessary to 
add, were not the mistake so often made, that true pruritus 
is in no way caused by either vegetable or animal parasites. 
When these are present, it is by accident. 

Pruritus is a functional affection, usually due to reflex 
nervous action. The nerve disturbance, unaccompanied by 
structural change, constitutes the whole process. The tissues 
remain unaltered throughout the entire course of the disease. 

The diagnosis of pruritus presents no difficulties. It is a 
disease of the skin, without any primary sign of alteration in 
its structure. Whatever lesions may be present are second- 
ary, and the result of scratching, or of strong applications 
made by the patient. The diagnosis depends upon the 
patient's statement as to the subjective symptom of itching. 
Pruritus is most apt to be mistaken for pediculosis, the 
secondary symptoms of the two diseases, scratch marks 



PRURITUS. 217 

and excoriations, being similar. These, however, are more 
marked and definite in character in pediculosis. The find- 
ing of lice will settle the question. They are to be carefully 
looked for in the clothing, and every case of so-called pru- 
ritus should be suspected to be pediculosis until the absence 
of the parasites is shown. 

The treatment of pruritus is a matter demanding careful 
consideration and study in each individual case. A success- 
ful result will, in most cases, only be attained by recognition 
and removal of the cause. Constitutional and local remedies 
are both demanded. The internal remedies are to be directed 
against the cause, whatever the nature of this may prove. 
If constipation exists, the bowels are to be suitably regulated, 
salines being usually preferable. If there is flatulence or 
dyspepsia of any kind, such a diet is to be prescribed as shall 
overcome the digestive difficulty, and coarse, irritating and 
indigestible foods are, in all cases, to be avoided. Exercise 
and fresh air are beneficial. A sojourn at some mineral 
springs, particularly those of Saratoga, may at times be 
recommended, when a course of the aperient waters, of which 
the Hathorn is best, may be taken. In many cases, close 
attention to these details will be followed by the most grati- 
fying results. 

As regards drugs, the usual tonic and alterative medicines 
are to be employed. Irregular menstruation must be treated 
by the judicious use of iron or other remedies, cod-liver oil, 
etc. Quinia and strychnia are sometimes of use. Recourse 
may be had to bromide of potassium and chloral, alone or 
together, in order to subdue general nervous symptoms. 
Morphia should in no case be used, as it tends to aggravate 
the itching. 

External treatment affords great relief, and is to be used 
in all cases. Cold and hot douches, used alternately, or hot 
water, applied as hot as it can be borne, or plain vapor baths 
15 



218 DISEASES OF THE SKIN. 

are often useful. Medicated baths, containing three to six 
ounces of bicarbonate of sodium, or two to four ounces of 
carbonate of potassium or borax, to thirty gallons of water, 
will, at times, afford relief. Sulphuret of potassium and 
sulphur- vapor baths are sometimes used with success. Inunc- 
tions with a bland oil, as almond oil, may be practiced after 
these baths. 

Lotions of various kinds are the most generally useful appli- 
cations in pruritus, and those containing carbolic acid are, 
by far, the most generally efficient. Carbolic acid, in fact, 
is worth all the other remedies put together as an anti-pruritic, 
and should always be preferred, to begin with, unless some 
reason exists against its use. It may be employed in lotion, 
in the strength of five to twenty grains to the ounce of water, 
with a little glycerine. In the following lotion the anti- 
pruritic effect of potash is added to that of carbolic acid : — 

R. Acidi Carbolici gj 

Potasses Fusae gss 

Aquae f^ viij. M. 

When other remedies fail, oil of peppermint may be 
applied, especially over circumscribed, itchy localities, avoid- 
ing the mucous and muco-cutaneous surfaces when such 
applications are apt to give pain. Morphia in solution, one 
to three grains to the ounce; cyanide of potassium, fifteen 
to thirty grains to the pint; dilute hydrocyanic acid, from 
one to four drachms to the pint ; chloroform ; chloroform 
and alcohol, a drachm to the pint ; lead water ; dilute ammo- 
nia water; dilute nitric acid, ten minims to the ounce of 
water, acetic acid or vinegar ; chloral lotion, ten to thirty 
grains to the ounce of water, are all serviceable remedies, 
which may be tried singly or in succession in troublesome 
cases. " Liquor picis alkalinus," an alkaline solution of tar, 
the formula of which is given under eczema, is a most 
valuable remedy. It should be used at first in the strength 



PRURITUS. 219 

of two or more drachms to the pint of water, gradually 
increasing. 

In some localized forms of the disease ointments are to be 
used in preference to lotions ; the following is a good one : — 

R. Acidi Carbolic! gr. x-xv 

Ung. Zinci Oxidi ^j. M. 

The following is recommended in pruritus vulvae (though 
ointments should rarely be used in this form of pruritus) : — 

B . Hydrarg. Chlor. Mite, 

Ext. Belladonnae aa 5J 

Ung. Aquae Rosae 3J. M. 

The following is a good ointment, but not to be used on 
abraded surfaces, and only with caution on the muco-cutaneous 
surfaces:— 

R . Camphorce, 

Chloralis Hydratis aa ^j 

Ung. Aquae Rosae ^j. M. 

The camphor and chloral are to be rubbed together until 
fluid, and then added to the ointment. The mixture may 
also be used as a lotion with glycerine and water. 

In pruritus of the female genital organs, water as hot as can 
be borne, sponged upon the parts, forms an admirable anaes- 
thetic, and should be used in all cases, whatever other treat- 
ment is added. Sponging with hot water may be followed 
by the application of one of the following lotions: Carbolic 
lotion, as given above; decoction of tobacco, two drachms 
of the leaf to the pint ; sulphurous acid ; or, solution of alum 
in barley water. A prescription containing a drachm of the 
sulphite of sodium, four drachms of water and an ounce of 
glycerine may be painted on. Sometimes emollient poultices, 
particularly a poultice of freshly-made almond meal, which 
evolves a small quantity of hydrocyanic acid, will be found 
very soothing. 



220 DISEASES OF THE SKIN. 

Pruritus ani is generally best treated by means of ointments. 
One of the best of these is an ointment containing two drachms 
of tar to the ounce of cold cream. Another, composed of 
equal parts of belladonna and mercurial ointments, is to be 
applied on a pledget of lint. An oil, composed of half a 
drachm of carbolic acid in an ounce of oil of sweet almonds, 
is a more agreeable application than those mentioned, and I 
think just as efficacious. Penciling with oil of peppermint, 
pure or with an equal proportion of glycerine, may do in 
mild cases, where the patient does not scratch and tear the 
parts, but it cannot be employed where there are abrasions or 
fissures of the muco-cutaneous surface. The application of 
any of these remedies should be preceded by sponging with 
very hot water. 

In pruritus scroti the following prescription will be found 
useful : — 

R. Bismuthi Subnitratis gij 

Acidi Hydrocyanici fgij 

Mist. Amygdalae f ^ iv. M. 

In the pruritus of jaundice, mercurial ointment is said to be of 
value, also lotions of chloroform (one drachm to five of glycer- 
ine) cyanide of potassium (one drachm to the pint of water), 
and acetic acid baths or lotions in the strength of half a pint 
of the acid to three gallons of water, or about two quarts of 
strong vinegar to an ordinary thirty-gallon bath. I may 
say here that a solution of benzoic acid, alone or with an 
alkali, is known to aid in the dispersion of bile pigment, and 
may, therefore, aid in the relief of this form of pruritus. I 
have not, as yet, had an opportunity to try this. 

I cannot leave the discussion of this important subject, the 
treatment of one of the most painful and annoying of all dis- 
eases of the skin, without adding some general remarks, the 
result of my experience, not only in the treatment of pruritus, 
but also of other skin diseases of a chronic and stubborn 



PRURITUS HIEMALIS. 221 

nature. In all of these much depends upon the care and 
thoroughness with which the physician's directions regarding 
diet and regimen are carried out. To ensure this the direc- 
tions themselves must be full and explicit. The patient's 
case must be made the subject of careful study; the exact diet 
suitable to the individual must be decided upon and enforced 
in such terms as to leave no doubt in the patient's mind as 
to the importance of every detail. Generalities in the way of 
directions, with a careless indication, in broad terms, of the 
articles of diet to be used and avoided, are not likely to pro- 
duce a serious impression on the patient's mind, and the 
failure to amend is followed by a general despondency and 
distrust of all remedies. 

The prognosis of pruritus should be guarded. The dis- 
order, as a rule, is obstinate ; often extremely so. The 
prognosis often depends largely upon the cause and our ability 
to remove it. The patient must be encouraged to persevere 
with and thoroughly carry out the treatment. In grave cases 
melancholic symptoms may be present. Occurring in the 
aged, the prospect of ultimate cure is poor. In the middle- 
aged, pruritus vulvae is the commonest form met with; a 
most distressing malady and one which calls for every possi- 
ble effort to ameliorate it on the part of the physician. 

Pruritus Hiemalis, or winter pruritus, is a peculiar form 
of itching, dependent upon atmospheric influences and occur- 
ring chiefly in cold weather. It usually makes its appearance 
in October, and lasts until spring, being worse in clear, frosty 
weather, and disappearing at times, if the weather becomes 
warm and moist. It occurs chiefly on the inner surfaces of 
the thighs, about the knees, the calves and the ankles. The 
affection may be relieved, but not usually cured. Emollient 
ointments, as vaseline and glycerine, with alkaline baths, give 
most relief. Occasionally the carbolic acid wash is useful. 
The undergarments should be soft and unirritating. 



222 DISEASES OF THE SKIN. 

Psoriasis. Psoriasis is a chronic disease of the skin, 
characterized by reddish, slightly elevated, dry, inflammatory 
patches, variable as to size, shape and number, covered with 
abundant, whitish or grayish mother-of-pearl colored, imbri- 
cated scales. The disease varies greatly in its extent and 
intensity in different cases, sometimes showing a typical 
development ; in other cases represented by one or two ob- 
scure lesions. It possesses, almost invariably, however, cer- 
tain characters which serve to identify it. The lesions begin 
as small, reddish spots, scarcely raised above the level of the 
skin, which almost immediately become covered with whitish, 
imbricated scales. They often develop rapidly, reaching the 
size of coins in a few weeks. At other times the course of 
the disease is more sluggish. The extent of the eruption 
varies greatly. A few patches may be all that are present, 
or the entire surface from head to foot may be involved, 
with scarcely a clear spot to be found. Commonly the dis- 
ease shows itself in the form of variously-sized, scaly patches, 
scattered over different parts of the body. The patches are 
characteristic. They are usually rounded, sharply defined 
from the surrounding skin, and consist of a mass of imbri- 
cated, yellowish-white scales on a red base. When the scales 
are picked off, a smooth, shiny, reddish surface is shown 
underneath, on which can be perceived a few pin-point-sized 
drops of blood. The abundance of the scales is a marked 
feature in some cases, where they are formed rapidly ; that 
is, in well-developed cases the patient's bed may be filled in 
the morning with a handful of scales, which have accumulated 
during the night. When the disease exists about the joints 
fissures may show themselves. There is no watery discharge 
at any period of the disease. Sometimes the eruption takes 
on a highly inflammatory character, with redness, swelling 
and severe burning and itching, while at other times all these 
symptoms are much less marked, and, in fact, the patient 



psoriasis. 223 

would hardly be aware of the existence of the disease, except 
for its appearance. Though the individual patches of psori- 
asis may be small, and generally are so, yet they sometimes 
coalesce into hand-sized or larger patches, or may even cover 
the greater part of a limb. 

Psoriasis may occur on any part of the body, but is most 
apt to be seen on the extensor surfaces of the limbs. It is 
sometimes found on the elbows and knees when it shows 
itself nowhere else. The back is more commonly attacked 
than the chest, and the scalp is a frequent seat of the disease. 
In the latter locality it sometimes occurs in patches, but 
more frequently as a diffuse and abundant scaliness. It is 
apt to extend a little beyond the border of the scalp, espe- 
cially behind the ears and on the forehead, and this is quite 
characteristic. Psoriasis does not occur upon the mucous 
membranes. The so-called il psoriasis of the tongue" is 
probably some different condition. Psoriasis is not conta- 
gious. 

The cause of psoriasis is not known. It is apt to occur in 
well-nourished, rosy-complexioned, light-haired people, the 
"picture of health," excepting that they are apt to be a little 
rheumatic. Now and then, however, it is met with in thin, 
worn persons, who are in poor health. Psoriasis rarely occurs 
in children, though Stelwagon has reported a case where it 
occurred in a child between three and four years of age. It 
rarely appears to be hereditary, but this tendency is occasion- 
ally met with. Some cases of psoriasis are worse in winter, 
and disappear almost or entirely in summer; others are 
worse in summer. Diet, I think, has little influence in 
causing the disease, though in some cases it may influence 
its course quite markedly. Psoriasis and syphilis are not 
connected in any way. There is a syphilitic eruption, some- 
times called "syphilitic psoriasis," because the lesions re- 
semble those of psoriasis. This most unhappy term has 



224 DISEASES OF THE SKIN. 

caused much confusion of mind, but it must be remem- 
bered that the cause, course and treatment of syphilis differ 
in toto from those of psoriasis. (See the Papulosquamous 
syphiloderm.') 

The diagnosis of psoriasis is easy when the affection is 
well-developed and presents its typical appearance. The 
form and aspect of the lesions, and the history of the case, 
will usually serve to determine its nature. Scanty and ill- 
developed eruptions of psoriasis are, however, at times, dis- 
tinguished only with difficulty. Nevertheless, it is an im- 
portant matter to accurately determine the nature of the 
disease, for its treatment is widely different from that of 
the affections with which it is liable to be confounded ; its 
prognosis also is different, and in addition, two of the other 
affections are contagious. 

Two or three small patches of psoriasis occurring alone, 
upon the arms or legs, may be mistaken for eczema. Itching, 
however, is always present in eczema, and therefore, itching 
is one sign that an eruption in question is not of this nature, 
though not a sure one, since psoriasis also sometimes itches. 

In the majority of cases of eczema, there will be a history 
of moisture at some time. Psoriasis is always dry and scaly ; 
never moist. The scales of psoriasis are more abundant, 
larger and whiter, than those of eczema. The patches of 
eczema are usually bold and well-defined in outline, while 
those of eczema fade into the surrounding skin. 

Syphilis, in the form of the papulo-squamous syphiloderm, 
is very apt to be mistaken for psoriasis and vice versa. Psori- 
asis, however, is more apt to be symmetrical in its distribution. 
It inclines to involve a large portion of the surface at once, 
or to be found in regions remotely separated, which the 
squamous syphilitic eruption rarely does. In psoriasis the 
lesions seem to be on the surface, so to speak. They are 
very scaly, but without much infiltration. The syphiloderm, 



psoriasis. 225 

on the other hand, is deeply indurated, and is only scantily 
covered with scales. In psoriasis the knees and elbows are 
apt to be involved. In syphilis these are not often attacked. 
Occurring on the palms or soles, the disease is apt not to be 
psoriasis, which is very rare in this locality. The color, 
though often deceptive, sometimes aids in diagnosis. It is 
usually much lighter in psoriasis, while in syphilis it is apt to 
be a dusky, ham color. The age of the patient, and the 
duration of the disease, may give a clue to the diagnosis. 
Psoriasis generally first shows itself before the age of twenty ; 
this form of syphilis later. The history of psoriasis is that 
of a chronic disease, lasting for years continuously, or in an 
intermittent manner. Syphilis rarely retains one form for 
any length of time. Other points in the history, infection, 
the occurrence of other lesions, etc., may come into use. 
Itching is rare in syphilis, common in psoriasis. Finally, 
the touchstone of treatment may be resorted to in very 
obscure cases. 

Tinea circinata and psoriasis are sometimes mistaken for 
one another, but the patches of tinea are less inflammatory, 
red and infiltrated, and are much more superficial. The 
scales in tinea are larger and lighter, and the patches show 
no attempt at symmetry. The microscope shows the exist- 
ence of a fungus in the scales of tinea circinata, which is 
absent in psoriasis, and a history of contagion may often 
be obtained in the former disease which is absent in the 
latter. 

Psoriasis may occasionally be mistaken for seborrhcea, as 
this disease occurs on the chest and back ; it may also be 
confounded with severe forms of lupus. A comparison of 
the description just given of psoriasis with that of the two 
former diseases, will show in what points the difference lies. 

The constitutional treatment of psoriasis, like that of ec- 
zema, should be based on a careful study of the history and 



226 DISEASES OF THE SKIN. 

habits of the patient. Attention should be given to the 
patient's general health and his condition, whether stout and 
well-nourished, or thin and delicate. Regard must be had 
also to any functional derangement. The history of the 
eruption itself must also be inquired into, as to its acuteness 
or chronicity, as to local and constitutional treatment which 
may have been previously employed, together with the effects 
of the same. In addition, inquiry should be made regarding 
the influence of the seasons, and whether the eruption is apt 
to disappear for a time and to break out again. 

Fortified with this knowledge the medical treatment can be 
entered into intelligently. In the large majority of cases 
arsenic is pre-eminently the remedy. But, while arsenic is as 
near a specific as, in the nature of things, it is possible for 
any medicine to be, yet it must be employed judiciously if its 
good effects are to be obtained, or even if we do not wish to 
do harm. Arsenic should not, as a rule, be given where 
there is much gastric irritation, and it is hardly necessary to 
say that it should not be continued, should it disagree even 
slightly. The patient should be warned of its possible effects, 
and should be under the constant watch of the physician ; 
on the first symptom of indigestion, pain in the stomach or 
bowels, or diarrhoea, the dose should be lessened or the use 
of the medicine suspended. Large or almost toxic doses do 
not hasten the cure of psoriasis ; they sometimes even retard 
it by upsetting the stomach. Sometimes only a minute dose, 
as half a minim of Fowler's solution, is borne at first, when, 
later, tolerance is gained and a full dose given. Some patients 
need and will bear large doses of arsenic, but this idiosyn- 
crasy must be learned by careful, tentative increase of the 
dose, beginning always with a moderate one. Arsenic should 
not usually be given in acute and inflammatory forms of 
psoriasis. Arsenic acts slowly. When, in a case of psoriasis, 
it is going to do good, improvement generally begins to be 



psoriasis. 227 

shown after two or three weeks, but to get the full benefit of 
the drug it must be given for several months, and its admin- 
istration should be continued for several months after the 
eruption has disappeared. Liquor potassii arsenitis, or Fow- 
ler's solution, is the best form in which to administer arsenic. 
It should never be directed in drops, as mistakes are likely to 
occur. It may be administered in water alone, or in a bitter 
infusion or tincture, or with wine of iron : — 

R. Liq. Potas. Arsenit sjij 

Vini Ferri ad f ^ iv. M. 

SiG. — A teaspoonful in water, after meals. 

The dose here is four minims — a fair average dose for an 
adult. The amount may be gradually increased, say every 
week, until an effect upon the eruption becomes perceptible, 
or until the limit of tolerance is reached. 

Sometimes it is desirable to give arsenic in pill form : — 

$. Pulv. Acidi Arseniosi gr. ij 

Pulv. Piperis Nigrae, 

Pulv. Glycyrrhizge Rad...aa.... ►) ij. M. 
Fiant pil. No. xl. 
SiG. — One after meals. 

Or occasionally powders may be preferred : — 

$. Pulv. Acidi Arseniosi gr. ij 

Pulv. Sacch. Lactis gr. cl. M. 

Fiant chart. No. xl. 
SiG. — One after meals. 

But neither pills nor powders are as effective as Fowler's 
solution, and I rarely prescribe them unless forced by circum- 
stances. 

Some cases of psoriasis require tonics, evidently, from the 
appearance of the patients ; others will be found, on experi- 
ence, to demand such treatment. Tincture of the chloride 
of iron is the best medicine to use in those meagre, worn- 
looking persons, as nursing mothers when the attack has 



228 DISEASES OF THE SKIN. 

come on during lactation. Next to iron in value is cod-liver 
oil, and these remedies occasionally succeed when arsenic 
fails. In acute inflammatory cases diuretics are occasionally 
of service. Acetate of potassium, in half drachm doses, may 
be given three or four times a day, in a wineglass of water. 
The alkaline mineral waters are also of service. Other drugs 
have been administered in psoriasis, but I think that those 
just mentioned will be found sufficient. 

The local treatment of psoriasis is of more or less import- 
ance, according to the nature of the case. When the lesions 
are few, small and widely disseminated, and there are no 
disagreeable subjective symptoms, local treatment is incon- 
venient and need not be employed. When, however, there 
are a few large patches, or when the eruption is situated on some 
conspicuous part of the person, or gives rise to annoying 
burning or itching, local treatment is required and will be 
found advantageous. If there are scales, these should be first 
removed by rubbing with sapo-viridis and hot water, or by 
the use of a hot-water bath. If the patches are few in num- 
ber, large and very scaly, the following solution, well rubbed 
in, will remove the scales readily and give an opportunity for 
making healing applications: — 

&. Acidi Salicylici %] 

Alcoholis f ^ iv. M. 

This is especially useful on the scalp, when, after the scales 
have been cleansed off by this means or by means of spiritus 
saponis kalinus (two parts of sapo viridis dissolved in one 
part of hot alcohol and filtered) used as a shampoo, an oil 
composed of one drachm of oil of cade to the ounce of oil of 
almonds or of alcohol may be well rubbed in by the aid of a 
soft tooth brush. On the edge of the scalp and about the 
face the best ointment is that of ammoniated mercury, twenty 
to forty grains to the ounce. 
When it is desirable to get rid of the scales and patches in 



psoriasis. 229 

the most rapid manner possible chrysarobin (chrysophanic 
acid) is the best application. An ointment of half a drachm 
to a drachm to the ounce is very efficient, and will remove a 
patch in a few days, leaving a white spot of skin surrounded 
by a purplish areola in its place. But there are strong objec- 
tions to the use of chrysarobin. It discolors everything with 
which it comes in contact, dyes the hair orange-yellow, and 
ruins the clothes. It cannot be used on the scalp, nor about 
the eyes and cheeks, because it gets up a sort of erysipelas 
there, and it cannot be trusted in the hands of most patients, 
because, unless used cautiously, it may inflame the skin 
wherever used. G. H. Fox has suggested the following 
solution, which is quite effectual and saves the smearing 
which renders the chrysarobin ointments so annoying and 
disagreeable : — 

R. Chrysarobin ^j 

^Etheris et, Alcoholis aa q. s. 

Collodii 3J. M. 

Rub up the chrysarobin with a little alcohol and ether, and 
add to the collodion. It forms a sort of emulsion, which 
should be shaken before using. By the aid of a camel' s-hair 
pencil in the cork, this may be painted over the affected 
patches after removal of the scales. When it dries, it will 
not come off on the clothes, a great advantage. 

Next to chrysarobin in activity comes pyrogallic acid. 
This may be used in ointment — a drachm to the ounce. It 
is almost as effectual, and is much more cleanly, although it 
leaves a blackish stain. I think it the best local application 
for psoriasis. The only caution to be observed is, not to rub 
it over a large area, say a quarter of the surface of the person, 
at any one time, for fear of absorption. Preparations of tar 
have been used from time immemorial in the treatment of 
psoriasis, but I think the remedies above mentioned are 



230 DISEASES OF THE SKIN. 

better, and they are certainly much more agreeable. When 
there is a good deal of itching, however, tar may be used, 
either as an ointment, of one to two drachms to the ounce, 
or in the following formula : — 
R . Saponis Viridis, 

Picis Liquidae, 

Alcoholis :..aa giv. M. 

This is to be rubbed firmly into the patches, previously 
denuded of scales, twice daily. 

In very severe and extensive, or universal psoriasis, baths 
with inunctions of bland oils and fats are better than any of 
the applications mentioned. Tar may be used in these cases 
cautiously. 

The prognosis of psoriasis, so far as the individual attack 
is concerned, is, in medium and mild cases, usually favorable. 
But the disease is prone to relapse, and the physician should 
warn his patient that, while the attack can be cured, the 
affection is liable to return, and that no treatment, however 
well directed, will surely prevent the disease from coming 
back. Severe cases, especially when the entire surface is 
covered with the disease, are often rebellious to all treatment. 

Purpura (iii). Purpura may be idiopathic or symp- 
tomatic. The idiopathic form commonly presents itself in 
two varieties, P. simplex and P. hemorrhagica. Purpura 
simplex is characterized by the appearance, in successive 
crops, of numerous petechial spots in the skin and visible 
mucous surfaces. These are usually attended with little or 
no constitutional disturbance, although malaise, loss of appe- 
tite, etc., may precede the outbreak of the eruption by some 
days. The spots come out suddenly, often in the night, and 
the patient finds his skin, usually the legs and about the 
knees, strewn with the sharply- defined, pin-head to pea-sized 
hemorrhagic lesions. The color of the eruption, at first 
bright red, soon becomes purplish, and the lesions may be 



PURPURA. 231 

single and scattered, or here and there mingled in irregular 
patches. The only subjective symptom observed is slight 
itching on the appearance of the lesions ; often even this is 
absent. Occasionally wheals, like those of urticaria, occur 
with the hemorrhages, and then there may be much itching. 
Blebs have been noticed in this form of purpura. 

Purpura simplex is more frequently observed in the old 
than in the young. An attack may last from a fortnight to 
several months, the cutaneous lesions coming out in crops. 
The causes are often obscure ; it occurs in the well-nourished 
as well as the debilitated. Malarial influences also have an 
effect in causing the disease. 

The lesions of purpura simplex are so peculiar, being small 
hemorrhages under the skin which do not disappear on 
pressure, that there is usually no- difficulty in making a diag- 
nosis. The lesions may, however, be confounded with flea- 
bites. The puncture made by the insect in the centre of 
each hemorrhagic point will, however, settle the diagnosis. 

There is one form of purpura simplex which is known as 
" P. rheumatica," where the prodromal symptoms are more 
severe, and where severe rheumatic pains are felt, especially in 
the joints of the lower limbs. When the eruption comes out 
the rheumatic symptoms abate ; relapses here are common ; 
the disease may last for months, and sometimes takes on the 
appearance of erythema multiforme. 

The second variety of idiopathic purpura, P. hemorrhagica, 
is a much more severe disease. It begins by marked pro- 
dromal symptoms, as debility, loss of appetite, languor, 
headache, and feelings of general distress. The spots of 
eruption appear suddenly, first upon the limbs and then 
spreading to other parts of the body, occurring usually in 
great numbers and often coalescing to form hand-sized 
patches. Hemorrhages from the mouth, gums, nose, stomach, 
bowels and bladder, and even into the brain, may occur 



232 DISEASES OF THE SKIN. 

simultaneously and the disease may have a fatal termination. 
The disease may occur at all ages and among the strong and 
well nourished as well as among the weak and ill-fed. 

Purpura hemorrhagica is liable to be confounded with 
scurvy, but scurvy occurs in those who have been subjected 
to bad food and improper hygiene. P. hemorrhagica comes 
on suddenly, scurvy comes on slowly, with tumefaction of 
the gums, bleeding and looseness of the teeth, etc. 

The symptomatic forms of purpura are those in which the 
hemorrhage into the skin is a comparatively insignificant 
symptom of a more important disease. The specific fevers, 
various forms of anaemia, leucocythemia and scurvy form one 
group of these. Another is formed of cases where the extra- 
vasation of blood into the skin is caused by the ingestion of 
drugs. (See Dermatitis medicamentosa.) A third group in- 
cludes cases occurring from mechanical causes, as feeble 
circulation, varicose veins, thrombosis, etc. A fourth group 
includes all those cases in which the nervous system is 
primarily at fault, as tabetic purpura, purpura in connection 
with diseases of the central nervous system and neuralgia, 
etc. 

In the treatment of purpura attention must first be paid to 
the removal of the cause, if this can be ascertained. Nutritious 
diet, and above all, if the hemorrhage be extensive, perfect 
rest in the horizontal position, are important. In purpura 
simplex, ergot, iron and quinine, the mineral acids, together 
with frictions and cold baths are beneficial. Purpura 
hemorrhagica calls for prompt and decided treatment. In 
addition to perfect rest and diet in ordinary cases, tincture 
of the chloride of iron in doses of twenty to thirty drops, 
alone or with ergot and digitalis, may be given. Turpentine 
and acetate of lead, with opium, may be administered in some 
cases. Oil of erigeron, in five to ten-drop doses, on sugar, 
every two to four hours, is highly recommended . In severe 



SARCOMA OF THE SKIN. 233 

cases ergot may be given hypodermically, one grain every 
four hours. Electricity has succeeded when other reme- 
dies have failed. Finney recommends ergot and belladonna 
at first, and bark, ammonia, and the mineral acids later. 

The prognosis of all forms of purpura, except purpura 
hemorrhagica, is good. The disease is apt to be stubborn to 
treatment, however, P. rheumatica particularly so. The latter 
is a treacherous disease, and the prognosis should be guarded. 
Closely connected with purpura is the hemorrhagic condi- 
tion, known as "bloody sweat," or " haematidrosis," which 
consists in the appearance at the outlets of the excretory ducts 
of the sweat glands, of a reddish fluid containing blood. It is 
usually in small quantity and localized, and is a cutaneous 
hemorrhage, taking place about the sweat glands, and empty- 
ing itself through the sweat ducts. It is a very rare disease. 
Quinine Eruption. (See Dermatitis medicamentosa.} 
Rhus Poisoning. (See Dermatitis Venenata?) 
Ring Worm. (See Tinea circinata, T. tonsurans and T. 
sycosis. ) 

Rodent Ulcer. (See Epithelioma?) 
Rupia. (See Syphilis of the shin.) 

Sapo Viridis, a soft soap, made originally of herring fat 
and potassa, and containing about three per cent, of caustic 
potassa. The genuine soap comes from Stuttgart, in Ger- 
many, but I think there must have been some change made 
in the fatty constituents of late years, as it does not smell, 
by any means, so disagreeably as it used. 

Sarcoma of the Skin (vi) consists of shot, pea, hazel-nut, 
or larger sized, variously shaped, discrete, non -pigmented or 
pigmented tubercles, or tumors. Non-pigmented tumors, 
occurring as single or multiple growths upon the various 
regions, represent, perhaps, the commonest manifestations of 
the disease. They are smooth, firm, elastic, not markedly 
painful upon pressure ; in color, reddish, violaceous, or 
16 



234 DISEASES OF THE SKIN. 

brownish red. It is said that the multiple pigmented sarcoma 
always appears first upon the soles and backs of the feet. 
The disease may be mistaken for the papular syphiloderm, 
gummata, lupus and lepra. It occurs generally toward 
middle age. The disease is malignant, usually proving fatal 
in the course of a few years. Recently, hypodermic injec- 
tions of Fowler's solution, in the dose of two drops, gradually 
increased to nine drops, diluted with two parts distilled 
water, daily, have been used successfully. They are worth a 
trial, for no other treatment avails. 

Scabies (ix). Scabies, or the itch, is a contagious, animal 
parasitic disease, a sort of eczema or dermatitis, caused by 
the presence of an animalcule, the itch mite, in the skin. It 
is highly contagious. The female itch mite no sooner finds 
itself on the skin than it begins the work of burrowing, form- 
ing, just below the surface of the skin, a burrow in which the 
eggs are laid, the faeces deposited, and in which the itch mite 
lives. The male is said never to enter the skin, but to live 
upon the surface. After a time, a certain number of young 
itch mites are hatched forth, all of which begin at once to 
take care of themselves, and to burrow. Thus, the early 
symptoms of the disease are caused by the irritating presence 
of these parasites at various points, and characterized by 
the formation of minute, more or less inflammatory, puncta, 
papules and vesicles. Later, the burrows can be seen in the 
shape of more or less tortuous, beaded, yellowish or blackish 
lines, not thicker than a thread, and one-eighth to one-quarter 
of an inch in length. Later still, scratch- marks, blood crusts, 
etc., show themselves, and the disease spreads day by day. 

The affection usually begins about the hands, and especially 
about the fingers. The wrists, the penis in men, and in women 
the mammae, are next involved. The other softer and more 
protected parts of the body are then invaded. The axillse 
and buttocks are very apt to be attacked. The lower limbs 
are generally spared, excepting the toes in children. 



SCABIES. 235 

Itching, oftentimes very severe, is a marked feature of the 
disease, increasing in severity with its extension. It is worse 
at night, when the patient is warm in bed. 

The cause of scabies lies, as has been said, in the irritating 
presence of the itch mite in the skin. It is so contagious 
that it may be conveyed by bedding or clothes, or even by a 
shake of the hand. It is not a common disease in this country, 
occurring only in the proportion of one per cent, among all 
skin diseases, being led in frequency by eczema, thirty-one 
per cent. ; syphilis, ten per cent. ; acne, seven per cent. ; 
psoriasis, between three and four per cent.; and various 
others. In Europe, on the other hand, the unwashed popu- 
lations furnish a larger proportion of scabies than of any 
other skin disease. 

The diagnosis of scabies is, as a rule, not difficult. The 
presence of the burrow is sufficient to decide the matter, and 
this should be looked for in every suspected case. The mite 
itself may usually be extracted from the minute vesicle at the 
end of the burrow by the aid of the point of a pin or needle, 
but failure to capture it need not be regarded as negative evi- 
dence in the diagnosis, for it requires a good light, sharp eyes 
and some dexterity to succeed. The burrows must not be 
confounded with irregular lines of epidermis filled with dust 
or dirt. The resemblance is at first sight strong. In the 
majority of cases the burrows are only to be detected upon 
the sides of the fingers. The regions of the body mentioned 
as the favorite seat of scabies must be taken into consideration 
in making the diagnosis, and finally, it must be remembered 
that other affections may be concurrent with scabies upon the 
body. 

Once recognized, the disease is, in most cases, easily cured. 
The great point is to use the applications in such a manner 
that the parasite may be destroyed without undue irritation 
of the skin, and, indeed, with relief to this condition. When 



236 DISEASES OF THE SKIN. 

the case is recent a cure can be rapidly and easily effected, 
but when of old standing there is apt to be a good deal of 
eczema in connection with the scabies, and after the parasite 
is destroyed the eczema remains for treatment. The follow- 
ing ointment seems to cure the eczema while killing the itch 

mite : — 

R. Pulv. Naphtol gj 

Ung. Aquae Rosae ^j. M. 

On coarse skins sapo viridis may be used with the naphtol: — 

R. Pulv. Naphtol g.iss 

Saponis Viridis gv 

Cretae Alb. Pulv ^j 

Axungiae ^x. M. 

I have used one or another of these prescriptions exclu- 
sively, for a year or two past, and prefer them above all 
others. Sulphur is the old standard remedy, and may be 
used in the form of ointment, ranging in strength from one 
to four drachms to the ounce, according to the tenderness 
of the skin. 

The treatment, whatever it be, should be preceded by a 
hot bath with soft soap, after which the ointment should be 
rubbed in, and allowed to remain. After three days of treat- 
ment, a bath and an inunction being taken daily, the patient 
should report for inspection. Too vigorous a course of treat- 
ment may give rise to a. dermatitis, which will require weeks 
to cure. 

The prognosis of scabies is always favorable ; a week or 
two will suffice in average cases, but the irritation of the 
skin requires longer treatment to overcome. 

The "army itch," much talked of after the late war, was 
a severe form of scabies. 

Sclerema Neonatorum (iv) is a disease of infancy, 
appearing usually at birth, consisting of a diffused stiffness 
and hardness of the cutaneous and subcutaneous tissues, 
accompanied by coldness, cedema, swelling and general 



SCROFULODERMA. 237 

circulatory disturbance. The disease may be congenital, or 
it may appear during early infancy. It is commoner among 
premature children. It begins in the lower extremities and 
extends upwards. The infant looks like a frozen corpse. 
Spontaneous recovery rarely takes place. Treatment should 
be directed against the general condition. 

Scleroderma (iv) is a usually chronic skin disease, char- 
acterized by a diffuse, more or less pigmented, rigid, stiffened 
or hardened, hide-bound condition of the skin. The process 
may occupy weeks or months in evolution. When fully 
developed, the skin is stiff, rigid, immovable, firm, the part 
seeming as if frozen or carved out of wood. The course of 
the disease is variable. Sometimes it undergoes spontaneous 
involution, in other cases it may last a lifetime. Exposure 
to cold and dampness seems to have been the exciting cause 
in many cases. True scleroderma is an excessively rare skin 
disease. There is another disease allied to Morphcea which 
is also known by this name. (See Morphcea.} 

Scrofuloderma (vi). There are a number of skin diseases, 
so closely connected with the condition of the system called 
scrofulous as to be properly designated scrofulodermata. Of 
these, one of the commonest is that which begins in one or 
more of the superficial lymphatic glands, especially about the 
neck and clavicular region. The glands become enlarged, 
and the process extends to the skin overlying them, which 
becomes red and infiltrated. Finally a cold abscess forms, 
and is discharged through the skin, and an ulcer of slow 
progress, with undermined violaceous border, results. 

Another common form of scrofuloderm is the "gumma," 
thus called by Besnier. The most superficial form of scrofu- 
lous gumma begins as a small infiltration or node in the skin, 
of a livid red color. Increasing in size, slowly at first, and 
later more rapidly, it sometimes extends in one or more 
directions, involving the entire skin, and softening at one or 



238 DISEASES OF THE SKIN. 

more points to four small ulcers, with burrowing cavities 
from one to another. The discharge from these ulcers is 
usually sero-purulent or sanious, and occasionally bloody, and 
the skin may be undermined by numerous communicating 
galleries. Occasionally the disease takes on a diffuse, infil- 
trating form, spreading in an irregular patch over the skin, 
involving its entire surface, and giving rise to serpiginous, 
shallow ulcers. The deeper forms of scrofulous gummata 
form under the skin, and only appear on the surface at first 
as a livid, violaceous discoloration, and later break down 
into an indolent ulcer. The scrofulous ulcer is always indis- 
posed to heal. It looks as if it were on the very verge of 
cicatrization, but it does not actually scar over, or if it does 
a week or two later, the cicatrix may open in one place while 
forming in another. 

The form of scrofuloderm just described is usually met with 
about the face, beneath the lower jaw and around the neck. 
I have met with it occurring above or below the clavicle, or 
on the cap of the shoulder. It is usually accompanied by 
other symptoms of the scrofulous condition. Old scars, the 
result of previous lesions, may often be detected in one region 
or another. 

This form of scrofuloderm is to be distinguished from 
lupus vulgaris, and from syphilis by the presence of the con- 
comitant general symptoms of scrofulosis, and by the peculiar 
features of the lesions, which differ materially from those of 
lupus and syphilis. The characters of the primary lesions, 
the form of the ulcers and their course, and the amount of 
crusting, differs materially. When the diagnosis between 
scrofuloderma and syphilis is difficult, the history in some 
cases will aid. Finally, mercury may be given (not iodide 
of potassium) in puzzling cases. This, which will cure the 
syphilitic lesion, will not affect the scrofuloderm. 

Another and rarer form of scrofuloderma is characterized 



SCROFULODERMA. 239 

by the formation of papillary, wart-like or fungous growths, 
of a pale, bright dusky or violaceous red. The surface of 
these growths is ulcerated, with a thin discharge and some 
crusting. These lesions are apt to occur on the backs of the 
hands, and may go so deep as to lead to bone changes. 
The course of this form of scrofuloderma is exceedingly 
chronic. 

A fourth form of scrofuloderma may be referred to, which 
shows itself in small, hard, scattered, flat papules, with a 
raised, violaceous area. The lesions may occur on any part 
of the body, but are usually met with on the forearms, legs 
and face. At first they look like the pustular syphiloderm, 
but crust over after some weeks, leaving a depressed, pin- 
head-sized, well-like cavity in the lesion. Finally the lesion 
disappears, leaving a punched-out scar, like smallpox. This 
form of scrofuloderma is chronic to an extreme degree. New 
lesions form while the old ones are cicatrizing, and while the 
affection gives no trouble, it is very rebellious to treatment. 

The treatment of scrofuloderma should be both general 
and local. Cod-liver oil, iodine, usually in the form of 
iodide of potassium, or of Blancard's pills of iodide of iron, 
and iron alone, are most usually serviceable. Lately, Milton 
has reported excellent results from the administration of 
calomel or gray powder, two or three times a week, at bed- 
time, for a fortnight, with a saline every morning, so as to 
produce a daily action of the bowels. Then the mercurial 
is suspended for a fortnight to a month, the saline being 
continued. If the appetite fails, bitters and mineral acids 
are to be given. Locally, a mild zinc ointment. Milton 
lauds this treatment as curing when all else fails. 

Locally, the ulcers are to be treated, as a general thing, 
with stimulating ointments, those containing mercury in 
particular. Ointments and powders of iodoform are also 
useful. Tincture of iron and chlorinated soda solution may 



240 DISEASES OF THE SKIN. 

also be used. When the disease is extensive, scraping with 
the curette or sharp spoon, to remove the morbid tissue, as in 
lupus, is the quickest method. 

Scurvy, Land. (See Purpura.') 

Sebaceous Cyst (i), or " Wen," as it is popularly called, 
appears as a variously-sized, firm or soft, roundish tumor, 
seated in the skin or subcutaneous connective tissue. The 
skin covering the tumor is natural in color or whitish, from 
stretching. The tumors may occur singly or in great num- 
bers, and vary in size from that of a pea to a walnut or 
larger. They are usually firm, but sometimes doughy, and 
are generally freely movable and painless. Their usual seat 
is upon the scalp, face, back and scrotum, though they may 
be met with anywhere, even on the soles. They may last for 
years unchanged, but sometimes break down and ulcerate. 
They may degenerate into epithelioma in old persons. Some 
sebaceous cysts are flat, with a minute hole in the centre ; 
others tend to rise and become semi-globular. The latter 
are those commonly found on the scalp, where they are devoid 
of hair. 

The contents of sebaceous cyst may be milky or cheesy 
in consistence, and are often decomposed and fetid. The 
tumors are, in fact, nothing more than enormously distended 
sebaceous ducts and glands, the walls of which have become 
hypertrophied until they form a tough sac. 

The treatment of sebaceous cyst is excision. The cyst 
should be carefully dissected out, as otherwise the disease 
is apt to recur. 

Seborrhcea (i). Seborrhcea is a disease of the sebaceous 
glands of the skin, characterized by an increase in the quan- 
tity of the sebum poured out, and also, in most cases, by an 
alteration in quality of the secretion. There are two varie- 
ties, S. oleosa and S. sicca. 

Seborrhcea oleosa appears in the form of an oily coating 



SEBORRHCEA. 241 

upon the skin, giving it an unctuous and greasy feel. Its 
most common seat is on the scalp and about the face, par- 
ticularly the nose and forehead, where it appears as a greasy 
coating, containing more or less dust and dirt, and looking 
as though the skin had been smeared with dirty ointment. 
In the scalp it collects on the hair, giving it a dark, limp 
look, as if it had been freely oiled, or when the scalp is bald 
it looks as if oil had been poured over it. 

Seborrhea sicca, or dry seborrhcea, occurs in infants as 
the vernix caseosa or smegma of the newborn. Here it is 
almost physiological, and is usually soon removed. If it 
remain, it becomes a diseased condition, and as such is often 
seen on the scalp. Dry seborrhcea shows itself on both the 
hairy and non-hairy portions of the body, as a more or less 
greasy mass of scales, of a dirty yellowish color, and some- 
what adherent to the skin. On the scalp, these masses are 
larger and oilier, tending to cling to the skin in thick plates, 
and leaving, when picked off, a smooth, grayish, moist or 
oily surface beneath. In old persons the scalp, and some- 
times the region of the beard, is covered, to a greater or less 
extent, with a brown, adherent, greasy coating, which is 
essentially seborrhceic in character. 

Seborrhcea sicca of the scalp, like pityriasis, with which it 
is sometimes confounded (see Pityriasis simplex), is some- 
times followed in the young by premature baldness. If taken 
in time, however, baldness from this cause can be prevented, 
and it is desirable in all cases to remove the seborrhceic 
condition, even if it gives rise to little or no annoyance. 

Seborrhcea of the foreskin and glans penis is an abnormal 
flow of the normal secretion of this part, known as smegma 
preputii. If unattended to, it leads to balanitis, from the 
irritation of its rapidly decomposing sebaceous products. 

Seborrhcea is induced by a variety of causes, prominent 
among which is the chlorotic or ansemic state. It is more apt 



242 DISEASES OF THE SKIN. 

to occur about puberty, or in early adult age. It may occur 
in persons otherwise healthy. In such cases it is usually 
curable by local measures. 

The diagnosis of seborrhcea is usually not a matter of much 
difficulty ; the evidently sebaceous character of the lesions 
pointing out its nature with sufficient certainty. 

The treatment of seborrhcea should usually be both consti- 
tutional and local. Fresh air and exercise, especially in the 
case of young women, is to be insisted upon. Attention 
should also be paid to diet. The history should be looked 
into and any functional irregularities corrected when possible. 
Success in treatment often depends upon ascertaining and 
meeting the exciting cause in the individual. Cod-liver oil, 
iron and arsenic are the most generally useful remedies. The 
following is a useful prescription : — 

JJ. Tinct. Ferri Chlor., 

Acid. Phosphoric, dil f^j 

Syrupi Limonis f^ij- M. 

Sig. — Half a teaspoonful to a teaspoonful, in a wineglass of water, three 
times a day. 

Arsenic is best given in the form of Fowler's solution, in 
four-minim doses at first, gradually increased until the disease 
begins to disappear, or until the limit of tolerance is reached. 
It should never be prescribed to be taken in drops, but always 
in combination with some adjuvant. The following is an 
excellent formula : — 

R. Liq. Potas. Arsenit ^ij 

Vini Ferri ad f^i v - M. 

Sig. — Teaspoonful after meals, in water. 

The local treatment of seborrhcea is very important. In 
seborrhcea of the scalp the scales and crusts must first be 
removed. If hard and caked, as is sometimes the case in old 
people, the scalp should be soaked in oil over night. Hot 



SEBORRHCEA. 243 

water and castile soap will then remove the softened crusts, 
or, if this should fail, the alcoholic solution of sapo viridis may 
be employed. A tablespoonful of this (see Spiritus saponis 
kalinus) may be applied to the scalp with a sponge and a 
considerable quantity of warm water added, so as to make a 
lather. After vigorously shampooing the scalp for a few 
minutes, the soapy matters are to be washed away with an 
abundance of clear, warm water, the scalp dried quickly with 
a soft towel, and it is ready for the application of the more 
strictly remedial agents. These should be in the form of oils, 
if the hair is at all thick, because ointments are so apt to 
stick the hairs together and make a mess. The sort of appli- 
cation to be made will depend upon the condition of the 
skin. If much irritated, one of the simple oils, as this, will 
be found convenient : — 

R. 01. Moringge Nucis (Oil of 

Benne) IJ 

Pulv. Benzoini gr. v. M. 

Rub up together and digest over a water bath for three hours ; 
cool ; add three drops of absolute alcohol ; let stand for a 
time and filter. This makes a good basis for other oily mix- 
tures. Ol. ricini and ol. olivse, so often recommended for 
use upon the scalp, tend to dry and clog, but oil of Benne is 
a non-drying oil. It may be used without the benzoin. 
Generally the scalp will bear more stimulating applications. 
Of these carbolic acid is one of the most efficient, as in the 
following combination : — 

R. Acidi Carbolici BJ-f^J 

01. Amygdalae f^iv 

01. Limonis ^j 

Aquae Cologniensis ad ^ij. M. 

Sig. — Apply after washing. 

When there is little hair upon the scalp, the following 
ointment may be used : — 



244 



DISEASES OF THE SKIN. 



R. Sulphuris Prsecipitat £ss 

Ung. Petrolii giv. M. 

SiG. — A small quantity to be rubbed in, once a day. 

This preparation is also useful in seborrhoea about the 
body. 

Another preparation useful about both scalp and body, 
especially in S. oleosa, is this: — 

R. Acid. Tannic 3 ss -j 

Ung. Petrolii j§j. M. 

Mercurials are sometimes of value. Either the red oxide 
of mercury, ten to twenty grains to the ounce, or the oint- 
ment of nitrate of mercury, one to three drachms to the 
ounce of vaseline, may be employed. 

The prognosis of seborrhcea will depend upon the duration 
and extent of the disease and upon the patient's general 
health. Dry seborrhcea can generally be gotten well, under 
proper treatment, in a reasonably short time. But when in 
the scalp and mixed with more or less pityriasis, the prognosis 
is not so favorable. Premature baldness may follow neglected 
seborrhcea. If the hair has already begun to fall out a cautious 
prognosis must be given. Even if the most active treatment 
is followed out there is little hope of bringing back the hair, 
although its fall may be arrested. 

Shingles. (See Herpes zoster.} 

Smegma. (See Seborrhoea.) 

Spiritus Saponis Kalinus. A solution of two parts 
sapo viridis in one part alcohol, made by the aid of heat, 
and filtered. 

Strophulus. (See Miliaria.') 

Stye. (See Hordeolum.) 

Sudamen (i) (see Miliaria) is a non-inflammatory disorder 
of the sweat glands, characterized by minute translucent 
vesicles, the orifices of stopped-up sweat glands. The nature 
and treatment of the disease are essentially the same as that 
of Miliaria. 



sycosis. 245 

Sweat, Bloody. (See Purpura.') 
Sweat, Colored. (See Chromidrosis .) 
Sweat, Phosphorescent. (See Phosphorescent sweat.) 
Sweating, Excessive. (See Hyperidrosis.) 
Sycosis (ii). Sycosis is a chronic, inflammatory, non- 
contagious disease, involving the hair follicles, characterized 
by pustules, papules and tubercles, perforated by hairs, accom- 
panied by burning and itching. The disease is confined to 
the beard and hairy parts of the face. Papules and then 
pustules form, each one having a hair as its centre, and 
showing little inclination to rupture. The pustules are gen- 
erally discrete, but are sometimes so numerous as to be 
crowded together. They are accompanied by marked red- 
ness of the surrounding skin, sometimes by swelling, burning 
and pain. Unless the suppuration is profuse, the hairs cannot 
be extracted without giving much pain. The causes of the 
disease are not known. It sometimes occurs on the upper 
lip, however, following catarrh of the nose. It occurs equally 
in those who shave and those who do not. It is not contagious. 
The disease is essentially an inflammation of the hair follicles. 
In the early stages the hairs are firm in their follicles, but 
when there has been a good deal of suppuration they become 
loose, and may be pulled out. A cicatrix, with baldness, 
then results. 

Sycosis is apt to be mistaken for eczema of the beard, and 
more especially for tinea sycosis, or true barber's itch. From 
the latter it is, however, distinguished by several marked fea- 
tures. In both affections the hair follicles are attacked, but 
in the parasitic disease the lesions are simply large, rounded, 
red lumps, or variously-sized nodules, with few or no pustules. 
The hairs, however, in spite of the fact that there is no sup- 
puration about their roots, come away easily, and sometimes 
drop out spontaneously. The presence of the spores of the 
vegetable parasite, when looked for in the roots of the dis- 



246 DISEASES OF THE SKIN. 

eased hairs under the microscope, will greatly aid in the 
diagnosis. (See Tinea sycosis, .) From eczema of the beard 
sycosis is distinguished by the absence of oozing or itching, 
and also by the fact that eczema rarely attacks the beard 
without showing itself elsewhere. It spreads about in pustules 
and crusts in the neighborhood, while sycosis is strictly 
marked by discrete pustules, each with its hair running 
through the centre. 

External treatment is that most generally useful in sycosis. 
Exposure to irritating influences is to be avoided. The hair 
should be kept clipped close or shaved. The latter is to be 
preferred. Although painful at first, I regard it as the sine 
qua non of successful treatment, and usually insist upon it. 
In this, as in some other matters, it is only the first step 
which costs; after shaving a few times, the patient is brought 
to see the reasonableness of the procedure, by the comfort 
which it brings. Shaving should be performed every second 
or third day, according to the rapidity with which the beard 
grows. When shaving is to be performed for the first time, 
the hairs should first be clipped close, and then a poultice 
should be applied, to soften the crusts. When there is much 
inflammation, this poultice may be made of bread-crumb 
and dilute lead water, and applied cold. This is very sooth- 
ing. After such careful preparation, shaving is a much less 
painful operation than it would otherwise have been. Shav- 
ing having been established as a habit, the local medical 
treatment may be put into employment. When the disease 
is acute and there is a good deal of pain and swelling, 
black wash may be thoroughly applied every two or three 
hours, followed each time, so soon as it is dry, by oxide 
of zinc ointment, gently applied by means of the finger, or 
spread upon pieces of soft linen and bound upon the parts. 

The following wash, not to be followed by ointment, is 
likewise of service in acute sycosis : — 



SYCOSIS. 



247 



R . Pulv. Zinci Carb. Praecip., 

Pulv. Zinci Oxidi aa 5J 

Glycerinae f£ij 

Liq. Plumbi Subacetat. dil f 3 ij 

Aquae Rosae f ^ viiss. M. 

In subacute cases the following wash is very good : — 

ft. Sulphur. Praecipitat £ij 

Pulv. Camphorae gr. x 

Pulv. Tragacanth ^j 

Aquae Calcis f^i v > M. 

Sig. — Shake well, and apply two to four times daily. 

If ointments are to be employed, the following will be 
found soothing, in the acute stage : — 

R . Pulv. Zinci Carb. Praecipitat., 

Pulv. Zinci Oxidi aa gj 

Ung. Aquae Rosae 3jj. M. 

To be applied immediately after shaving. 

Another convenient ointment, slightly more stimulating, 
is the following: — 

R. Hydrarg. Chlor. Mitis gr. xv-xxx 

Ung. Aquae Rosae 

Ung. Zinci Oxidi aa ^ ss. M. 

When the affection is of long standing, and when there is 
much infiltration, sapo viridis well rubbed in with a flannel 
rag and a little water, and after washing off followed by 
ung. diachyli, may be employed. 

When the eruption exists only at one or two points, and 
is subacute or chronic, stronger stimulants may be used. 
Sulphur ointment, half a drachm to a drachm to the ounce, 
or one of the mercurial ointments, may be employed. 

Depilation is only to be used when the roots of the hairs 
are loosened by suppuration. 

The prognosis in sycosis should be guarded, for while 
some cases yield readily to treatment, others, particularly 



248 DISEASES OF THE SKIN. 

when the disease involves a considerable area of the face, 
last for months, and even years, in spite of the most assidu- 
ous attention. Relapses are not uncommon. 
Sycosis, Non-parasitica. (See Sycosis.) 
Sycosis, Parasitica. (See Tinea sycosis.) 
Syphilis of the Skin (vi). The syphilitic eruptions of 
the skin are characterized by certain features in common. 
These are: i. Polymorphism. 2. Peculiar color. 3. Rounded 
form. 4. Apyretic, indolent, non-itchy character. 5. Cura- 
bility by mercury. 

They will be conveniently considered under the following 
heads : I. Erythematous. II. Papular. III. Pustular. IV. 
Tubercular. V. Gummatous. VI. Bullous. (A vesicular 
and a pigmentary variety are described by authors, but they 
are so rare as to be almost non-existent.) 

The Erythematous syphiloderm is the earliest and one of 
the commonest manifestations of syphilis, but occurring, as 
it often does, upon the covered parts of the body, and giving 
rise to no subjective symptoms, it often passes unnoticed. 
It comes out from the sixth to the eighth week after the 
appearance of the chancre, but when mercury has been given 
from the first its advent may be very much delayed. It pre- 
sents itself in the form of diffuse macules of various sizes, 
and of a pale rose, later a brownish or yellowish tint. It is 
usually seen on the sides of the body and on the abdomen, 
chest and back, also on the flexor surfaces of the limbs, 
rarely upon the face and hands. The diagnosis of the 
erythematous syphiloderm is usually not difficult. It is 
commonly accompanied by some of the other symptoms of 
syphilitic infection, general malaise, nocturnal headache, 
wandering pains in the limbs, sore throat, etc. ; while not 
infrequently traces of the chancre and the engorgement of 
the inguinal, sub-occipital and other glands, can be made 
out. 



SYPHILIS OF THE SKIN. 249 

The erythematous syphiloderm runs a slow course, and is 
often accompanied, toward the last, by papular and other 
lesions, showing the polymorphous nature of the disease. 

The Papular syphiloderm is characterized by the appear- 
ance of small, hard, solid elevations of various size, not 
containing fluid, and of a coppery or ham-red color, termi- 
nating in resolution. It assumes various forms, small and 
large, scaly, moist, and vegetating. The small papular 
syphiloderm consists of single and disseminate or grouped, 
pin-head to small pea-sized, hard, round, or pointed papules, 
at first bright red in color, but later of a dusky tint. It is a 
well-marked eruption, generally occupying a considerable 
area, and found commonly about the shoulders, arms, trunk 
and thighs. 

The small papular syphiloderm may occur, as one of the 
early manifestations, as early as the third or fourth month, 
or it may occur later, after other lesions have occurred. 
Relapses are not infrequent. Other lesions, as large papules, 
small pustules and moist papules, are apt to be present at the 
same time. It is most likely to be mistaken for eczema, 
especially when it itches slightly, as it does at times, on its 
first appearance. It may also be mistaken for psoriasis. 
A reference to the description of these affections will show 
their distinguishing features. 

The large papular syphiloderm is, in some respects, similar 
to the smaller variety, but is met with in other localities, 
and shows fewer as well as larger lesions. Its favorite seats 
are the forehead, just beyond the scalp {corona veneris), about 
the mouth, nape of the neck, back, flexor surface of the 
extremities, scrotum, labia, perineum and margin of the anus. 
It is one of the commonest of all the syphilitic skin diseases. 
It may occur early or late, but is very apt to follow closely 
on or accompany the erythematous syphiloderm. This 
variety is more amenable to treatment than the small papular. 
17 



250 DISEASES OF THE SKIN. 

The moist papule (sometimes called " mucous patch," 
though this term should be restricted to lesions occurring on 
mucous membranes) is the ordinary papule, with its horny, 
epithelial surface macerated off, usually on account of the 
contact of two contiguous surfaces, as in the neighborhood of 
the anus and scrotum, and about the mouth. The surface of 
these patches is dusky red, moist and secreting. These lesions 
are the most dangerous, as to contagion, of all syphilitic 
lesions, and as many cases of chancre are derived from these 
moist papules and from true mucous patches of the inside of 
the mouth, as from chancres. The favorite seats for moist 
papules are the glans and scrotum in the male, the external 
genitals in the female, the umbilicus in infants, and the anus 
in all three. The diagnosis rarely presents any difficulty, 
because there are always concomitant lesions. 

Occasionally the moist papule takes on a luxuriant, papil- 
lary, warty growth, when the lesions are called vegetating 
papules. They resemble, but are on no account to be mis- 
taken for, the non-syphilitic, " venereal" or acuminated wart. 
The secretion of the vegetating papule is highly contagious. 
It does not, however, produce another vegetating lesion on 
the person inoculated, but an ordinary chancre. 

The papulo-squamous syphiloderm is a papular eruption, 
where the scaly element is prominent. It is chiefly interest- 
ing because it is apt to be mistaken for psoriasis — a misfortune 
rendered much more likely to happen by the perversity of 
some writers, who call this lesion "syphilitic psoriasis," a 
misleading and confusing term, which should never be em- 
ployed. The chief element of distinction lies in the fact 
that psoriasis is altogether a scaly disease, with but little 
infiltration, while the papulo-squamous syphiloderm shows 
comparatively few scales, with a hard, sometimes raised 
base. 

The syphilitic disease is not uncommonly found on the 



SYPHILIS OF THE SKIN. 251 

palms and soles, while psoriasis is very rarely found in this 
locality. (See Psoriasis. ~) 

The pustular syphiloderm occurs in a variety of forms. The 
pustules vary greatly in size, but are all characterized by 
the rapidity with which they crust, a rapidity increasing with 
the size of the pustule. The small pointed pustular eruption 
is abundant and usually occurs with some other and charac- 
teristic lesions ; it presents no peculiarities of interest except 
that, as it matures, the epidermis around the lesion raises 
and forms a ring or collarette which is very distinctive. The 
large pointed pustular syphiloderm is the eruption which 
used to be called {t syphilitic acne " (another barbarous and 
confusing designation). The pustules resemble those of acne, 
and still more those of smallpox, and when they occur upon 
the face, accompanied with high fever, care must be exercised 
in examining all the concomitant symptoms, or a mistake in 
diagnosis may be made, and a syphilitic patient thrust into a 
smallpox hospital. The crusts which result from the drying 
up of the pustules rest upon little ulcers, and this gives an 
important diagnostic point. For if, upon lifting a crusted 
pustule it displays a little well of pus beneath it, the lesion is 
syphilitic, while, if only an excoriation is seen, the lesion is 
almost certainly not syphilitic. In addition to acne and 
smallpox this syphilitic eruption is apt to be confounded 
with the iodide of potassium eruptions. (See Dermatitis 
medicamentosa.} 

The small, flat, pustular syphiloderm is made up of small, 
flat pustules aggregated in groups and rapidly crusting. It 
occurs chiefly about the nose, mouth, in the beard, on the 
scalp, and about the genitalia. On lifting the crusts a shallow 
or deep ulcer is found. It may be mistaken for impetigo or 
eczema, but ulcers are not found in those affections. It is 
one of the more benign syphilodermata. 

The large, flat, pustular syphiloderm shows itself in finger- 



252 DISEASES OF THE SKIN. 

nail-sized, flat pustules on a deep red base. Sometimes the 
ulcer underneath is shallow, at other times deep, punched out 
and secreting an abundance of pus, which may dry up in thick 
oyster-shell-like crusts (rupid). The shallow, ulcerated pustules 
of this variety are benign. The deeper ulcers generally 
occur in broken-down individuals and are of more unfavor- 
able significance. They can hardly be mistaken for any 
other disease. They occur in the ninth to the twelfth month 
of syphilis. 

The Tubercular SypJiiloderm. The eruption here consists 
of one or more solid elevations of the skin, varying in size 
from a split pea to a hazlenut ; smooth, glistening, rounded 
or somewhat pointed, hard, and felt to be deeply seated. 
Their color varies from a brownish-ham color, to a bright red 
or true copper color. Sometimes they have an intensely 
dusky red hue, a color not met with in any other disease 
of the skin. 

The lesions may occur singly or grouped sometimes in 
circles or crescents, occasionally melting together in indurated 
patches. Usually only a few lesions or a small patch occurs. 
This eruption is never diffused over a large area. 

Sometimes the tubercular lesions are grouped in a ser- 
piginous form, and occasionally they ulcerate and crust, but 
not to a marked degree. The eruption is indolent and occurs 
late in the history of the disease, rarely showing itself before 
the second year. Not infrequently its appearance is delayed 
to five, ten, even twenty years after the initial lesion, and in 
women, where the initial lesion and early symptoms are often 
overlooked or ignored, no " history of syphilis " can be ob- 
tained. Now and then vegetations may spring up on the 
tubercular syphiloderm, forming wart-like and cauliflower 
excrescences, with a fetid secretion. 

The tubercular syphiloderm is peculiarly liable to be mis- 
taken for lupus vulgaris. The tubercles of syphilis, however, 



SYPHILIS OF THE SKIN. 253 

are firmer, more deeply seated, and have a history of more 
rapid development. Lupus, moreover, appears usually first 
in childhood, while the tubercular syphiloderm is rarely seen 
before adult or middle age. Occurring on the face and 
especially in the region of the cheeks and canthus of the 
eyelids, the ulcerative tubercular syphiloderm may be mistaken 
for epithelioma, and this is the more easy because the syphilitic 
ulcer sometimes becomes converted into an epithelioma, o 
which I myself have seen two instances. The touchstone 
of treatment must be used here, and if the suspicious ulcer 
fails to yield to mercury and iodine it should be cauterized 
or excised. 

The Gummatous Syphiloderm. Gummata are among the later 
lesions of syphilis. They are usually situated primarily in 
the connective tissue, and only subsequently make their 
appearance in the true skin, but occasionally the skin is first 
attacked and the gumma appears as a more or less circum- 
scribed, slightly-raised, rounded or flat tumor, variable as to 
size and strongly tending to break down into an ulcer. The 
lesion resembles a blind boil or abscess, with its dusky, pur- 
plish color and almost fluctuating sensation under the finger. 
Gummata are usually solitary. When ulceration takes place 
the cavity is deep, but fills up rapidly as a cure takes place. 
Gummata are apt to be mistaken for furuncle, abscess, en- 
larged lymphatic glands, carcinoma, and for fibrous and fatty 
growths. Gummata are not unfrequently poulticed and then 
cut open, by too zealous surgeons, with great resultant chagrin, 
when the firm, dry walls gape, where pus was expected to flow. 
They should never be lanced, as it is much easier to cause 
resolution by appropriate remedies than to cure the open sore 
which follows cutting. 

The Bullous Syphiloderm is very rare. It is characterized 
by the appearance of blebs containing a clear, watery fluid, 
which soon tends to become cloudy and thick. Sometimes 



254 DISEASES OF THE SKIN. 

the lesion is more like a large pustule than a bleb. The 
lesions soon break or dry up with rupial crusts. When these 
are removed shallow ulcers are found. The bullous eruption 
is a late manifestation of syphilis, and is met with in the 
cachectic and broken down. It can only be mistaken for 
pemphigus or dermatitis herpetiformis, and in both of these 
affections the bullae contain serum and not pus, and rupial 
crusts are absent. 

The treatment of the syphilitic affections of the skin should, 
in the early diffused eruptions, be internal only. When the 
lesions are comparatively few in number and of some size, 
especially when they are ulcerative, local applications may be 
used with benefit. Finally, in the late and indolent ulcerative, 
tubercular or gummatous lesions, local treatment alone often 
suffices to heal the lesion, and since internal treatment, how- 
ever good, will not insure against a relapse, it need not 
necessarily be used. Mercury is to be employed in the earlier 
and generalized lesions. The protiodide of mercury, in doses 
of one-fourth of a grain, in pill-form, thrice daily, gradually 
increased until the disease yields or the gums are touched 
slightly, is the best average treatment. The biniodide of 
mercury is also very useful in doses of tV to j grain, dissolved 
in water, with the aid of a little iodide of potassium, when 
for any reason it is preferred to give the mercury in a fluid 
form. Iodide of potassium is to be reserved for the later 
lesions, or to mix with the mercurial in stubborn cases. A 
dose of five grains will be found large enough in the great 
majority of cases, but it must be pushed rapidly if the lesions 
do not yield. 

Local treatment is required, when the lesions are situated 
on the face and hands, and when it is desirable to hasten 
their disappearance by all means, or when ulcers, with pro- 
fuse and disagreeable discharge, are present in any part of. 
the body. For dry lesions, the ammoniated mercury oint- 



SKIN DISEASES IN HEREDITARY SYPHILIS. 255 

ment, or a twenty or ten per cent, oleate of mercury, may be 
rubbed firmly into the skin, once or twice daily. For moist 
lesions, a solution or stick of nitrate of silver may be em- 
ployed. In ulcers, bits of soft linen, cut a little smaller than 
the lesions and spread thickly with Ung. hydrarg. full or half 
strength, may be applied.* 

Skin Diseases in Hereditary Syphilis (vi). The 
syphilitic eruptions of infants are, in all respects, the same 
as those of adults, excepting in so far as their appearance is 
altered by the peculiarities of structure of the infantile 
integument. 

The mortality of syphilitic children is very great, fully 
one-third failing to reach maturity. Abortion, resulting from 
the death of the foetus, usually occurs about the sixth month. 
An aborted foetus is usually in a macerated condition, the 
skin being easily detached, and the surface having a livid 
purple color. The integument either shows nothing charac- 
teristic, or large bullae may be found on the palms and soles. 

Syphilitic children generally present a healthy appearance 
at birth, and, for a week or two, all seems to go well. Then 
symptoms of debility and decreased vitality show themselves ; 
the infant begins to emaciate, and grows wizened and 
aged in appearance. Catarrh of the nasal passages — " the 
snuffles" — shows itself, interfering with respiration, and thus 
sometimes itself alone being the cause of death. The skin 
becomes yellow, loose and wrinkled. It is drawn tight over 
the bones of the face, which become sallow and earthy, with 
prominent eyes and a peculiar senile expression, the infant 
presenting the appearance of decrepid old age. Now and 
then, however, excessive emaciation is not observed, even 

* To supplement the necessarily brief account of the syphilitic skin dis- 
eases and their treatment here given, reference may be made to the text- 
books on syphilis. I have given my own views at some length, in an 
article on Syphilis, in the International Encyclopedia of Surgery, Vol. II. 



256 DISEASES OF THE SKIN. 

when the syphilitic poison has affected the system to a 
marked degree. 

The erythematous syphiloderm is that which is earliest and 
most frequently observed in infants. It generally makes its 
appearance about the third week of life, often accompanied 
by coryza, and showing itself first on the abdomen, in the 
form of minute, round or oval, pink macules. It spreads 
rapidly over the surface of the body and limbs, and the 
patches grow larger and darker, until they may be half an 
inch in diameter, slightly or not at all elevated above the 
surface, coppery-red in color, and no longer, as at first, 
disappearing under pressure. There is usually little or no 
scaliness, excepting slight desquamation, at times, upon the 
hands and feet. 

This eruption is very liable to be confounded with the 
simple erythematous rashes of early infancy. The most im- 
portant diagnostic points are the tendency to infiltration, and 
the formation of papules in places where the skin comes 
together in folds, as about the neck, and especially in the 
region of the genitalia and nates. In addition, the tendency 
to scaliness about the palms, soles, and occasionally the nates, 
is more or less characteristic. Sometimes, however, it is 
impossible to distinguish between the syphilitic eruption and 
simple erythema about the nates, at first sight, and the case 
must be held under advisement for a certain time, local treat- 
ment only being employed, before a positive diagnosis can 
be given. The syphilitic eruption tends to get worse, show 
moist and infiltrated patches, etc., while other symptoms 
show themselves elsewhere. The eczematous eruption will 
either improve under local treatment or tend to show weep- 
ing and itchy patches, and vesicles or pustules. 

The papular syphiloderm in infants is usually met with in 
connection with the erythematous eruption, but sometimes it 
may occur first. The lesions are dull-red, small, flat papules, 



SKIN DISEASES IN HEREDITARY SYPHILIS. 257 

occasionally mingling to form a patch. When seated about 
the anus or genitalia, the lesions become changed into typical 
moist papules, and now and then vegetations or syphilitic 
condylomata grow out of these lesions. These are highly 
contagions, and must be carefully distinguished from the 
simple vegetations growing about these parts, in children 
who are poorly cared for. The latter are more apt to be 
smaller, more pointed and dry, and occur almost invariably 
near some muco-cutaneous juncture. They spring directly 
from the skin, while the syphilitic vegetations grow from an 
indurated, often moist, base. The simple vegetations are not 
so apt to have a fetid odor, whereas, the syphilitic condylo- 
mata secrete an excessively offensive sero-purulent liquid. 
Moist papules in the infant are apt to occur at the verge of 
the anus and the commissure of the lips. In the latter 
locality they lead to deep fissures, the scars of which form 
diagnostic marks of hereditary syphilis in later life. 

The pustular syphiloderm in infants may occur before the 
eighth week in children profoundly affected with syphilis, 
but usually shows itself at a later period. The pustules may- 
be large, numerous and deep, or few and small, according to 
the severity or mildness of the disease. The thighs, buttocks 
and face, are usually attacked. On the face they may coal- 
esce and form thick, green, crusted lesions, resembling those 
of impetigo or pustular eczema. The syphilitic crusts, how- 
ever, are dark, thick and greenish, while those of the other 
diseases are lighter. On removal of the crusts the syphilitic 
lesions are found ulcerated, while only a shallow erosion is 
found under the eczema and impetigo crust. Moreover, 
itching, which is very common in eczema, does not exist in 
the syphilitic lesion. 

A furunculoid eruption is sometimes met with in hereditary 
syphilis. The lesions begin as small nodules in the corium, 
and gradually increase to the size of half a nutmeg ; ulcers 



258 



DISEASES OF THE SKIN. 



form on the summit; sloughs are thrown off, and irregular, 
unhealthy cavities, with scanty, offensive secretion, are left, 
the lesions subsequently running a chronic course. They 
often result in cicatrices. 

Tubercular and bullar eruptions sometimes occur in heredi- 
tarily-syphilitic children ; the former show no marked differ- 
ence from similar lesions found in the adult. The bullar 
syphiloderm, the "pemphigus syphiliticus" of older writers, 
is usually found on the palms and soles. The skin shows 
patches of a violet color ; in a short time small, confluent 
vesicles make their appearance on these spots, and then 
coalesce and grow larger, until the fully-formed bullae show 
themselves, varying in size from that of a pea to a hen's egg, 
with a yellowish-green, opalescent color and purulent con- 
tents. The lesions maybe brownish or hemorrhagic; they 
break in a day or two, and leave shallow ulcers. The bullar 
syphiloderm is a symptom of grave import. It is important 
to distinguish it from simple pemphigoid eruptions. This 
may be done by noting its earlier appearance (it is congenital, 
or appears very soon after birth), its usually more serious 
character, and the concomitant symptoms and history. It 
is rarely the only symptom. Sometimes impetigo contagiosa 
may be mistaken for the bullar syphiloderm, but its non- 
ulcerative character, place of election, trifling severity, etc., 
should prevent this mistake. (See Impetigo contagiosa^) 

The treatment of hereditary, infantile syphilitic skin dis- 
eases is essentially that of the disease in general. Mercury 
may be administered by baths, inunctions, or internally. 
Warm, daily baths, each containing ten grains of the bichlo- 
ride of mercury, are frequently highly beneficial. A small, 
flannel skirt, with the waist tied around the infant's neck, 
and then spread over the edge of the tub, will permit it to 
splash, without danger of sending the fluid into its mouth. 
The dose is sufficient for any age, from one month to twenty. 



TINEA CIRCINATA. 259 

Inunctions of mercurial ointment, in full or in half strength, 
may be employed. The best procedure is to smear a piece of 
ointment, the size of a small walnut, thinly over a flannel 
band, and then pin it around the abdomen, not changing it, 
but applying fresh ointment daily, until the flannel becomes 
stiff. Gray powder is given internally by many physicians. 
I rarely use it. In the later furunculous and pustular 
eruptions the iodide of potassium, in doses of half a grain to 
two grains, according to the age of the infant, may be given 
with advantage. Inunctions of cod-liver oil, or the same 
internally, may be given at times, and nourishing and appro- 
priate diet is absolutely required. 

Syphiloderma. (See Syphilis of the skin.} 

Telangiectasis. (See Ncevus.~) 

Tetter. A popular name given to several diseases, but 
chiefly to eczema. 

Tinea. The name given to the vegetable parasitic dis- 
eases of the skin. Of these we have T. circinata, or ring- 
worm of the body, T. tonsurans, or ringworm of the head, 
T. sycosis, or ringworm of the beard, T. favosa or favus and 
T. versicolor, each of which will be described as clinically 
separate affections. 

Tinea Circinata (ix), or ringworm of the body, is a con- 
tagious, vegetable parasitic disease, due to the presence of 
minute spores and mycelia or threads growing in the epider- 
mis and giving rise to one or more circumscribed, circular, 
variously-sized, inflammatory, squamous patches, occurring 
on the general surface of the body, accompanied by itching. 
The disease usually begins as a small, reddish, scaly, rounded 
or irregular-shaped spot, which in a few days assumes a circu- 
lar form, healing in the centre as it spreads on the periphery, 
which is usually papular, but may occasionally be made up of 
small vesicles. Sometimes the rings coalesce and form gyrate 
figures. The disease may attack any part of the body, and is 



260 DISEASES OF THE SKIN. 

transmitted by contagion from one part to another. In chil- 
dren who have ringworm of the scalp more or less ringworm 
of the body is almost sure to be found at one time or another. 

Ringworm is eminently contagious, and is not only trans- 
mitted from one human being to another, but also from 
domestic animals, chiefly horses, dogs and cats. Children 
are more susceptible to the disease, although adults also may 
contract it. The diagnosis of ringworm may usually be 
made from its very peculiar clinical features, and also from 
examination of the scales by means of the microscope. A few 
scales soaked in a drop of liquor potassse and examined under 
a power of 350 diameters, will show long threads running 
across the epidermic cells, which are quite characteristic. 
Their absence, however, is not conclusive against the diagnosis 
of ringworm, as they are sometimes scanty and difficult to find. 

The treatment of tinea circinata is simple. The lesions are 
to be cleansed with soap and hot water, and then an ointment 
of ammoniated mercury, 15 to 40 grains to the ounce, maybe 
thoroughly rubbed in. The process to be repeated twice 
daily, until a cure is effected. In more stubborn cases, a 
lotion or ointment, of one drachm of sulphite of sodium to 
the ounce, or pure, strong sulphurous acid sopped on, will 
usually suffice. In obstinate ringworm of the thighs and groins, 
the following ointment is efficient. This is for adults : — 

R. Creasoti rr\,xx 

Olei Cadini f,^"j 

Sulphuris giij 

Potassii Bicarbonatis ^j 

Adipis j|j. M. 

There are other remedies innumerable, but those men- 
tioned will, one or another, generally suffice. 

Tinea Decalvans. A confusing term, indifferently applied 
to alopecia areata and to tinea tonsurans ; two widely different 
diseases in nature, appearance and treatment, as will be seen 



TINEA TONSURANS. 261 

by referring to the account of them given under their 
respective titles. 

Tinea Tonsurans (ix), or ringworm of the scalp, is pre- 
cisely the same disease as tinea circinata, above described, only 
occurring in the scalp. It is characterized by one or more 
usually circular, variously-sized, more or less bald, patches, 
covered with ashen-gray scales, with a "goose flesh" appear- 
ance, and numerous small, broken-off stumps of hair. Some- 
times the disease is disseminated, when a search through the 
scalp will show black points scattered here and there, which are 
the stumps of diseased hairs broken off level with the scalp. 
Ringworm of the scalp is a disease of childhood, and is not 
met with in the adult. It is highly contagious among children. 
Microscopic examination shows the hairs filled with roe-like 
spores, infiltrating their tissue and rendering them highly brittle. 

The diagnosis of ringworm of the scalp is usually easy. 
The only disease with which it is liable to be confounded is 
alopecia areata, but here the hairs fall out entire, leaving a 
smooth, ivory-like surface. Now and then squamous eczema of 
the scalp looks like ringworm, but there are no broken-off hairs. 

The treatment of ringworm of the scalp is tedious and 
difficult, because it is hard to get the remedies down to the 
roots of the hair, where the fungus greatly flourishes. Of the 
great number of remedies constantly turning up, almost all 
would be good if they could be gotten into contact with the 
fungus, but the best will fail if it cannot be made to reach 
the last and remotest spore in the deepest hair follicle. 

As a preliminary to treatment, the hair should be cut short, 
scales should be cleansed from the scalp, and the diseased 
hairs should be pulled out by means of convenient forceps, 
immediately after which the parasiticide should be applied. 
In boys, when the eruption is extensive, the scalp may be 
shaved from time to time. Daily epilation of diseased hairs 
is an exceedingly troublesome, but very necessary procedure. 



262 DISEASES OF THE SKIN. 

Among local remedies carbolic glycerine is one of the best. 
It may be applied to the diseased patches in strength varying 
from i in 8 to i in 3, according to the age of the patient, 
while a weaker lotion of the same should be smeared over the 
scalp generally, to prevent drying of the scales and spread of 
the contagion. 

An ointment highly recommended by Alder Smith is the 
following: — 

R. Acid. Carbolic. Cryst., 
Ung. Hydrarg. Nitrat., 
Ung. Sulphuris aa Jjss. M. 

The ingredients are to be mixed without heat. This 
ointment may be used in children over eleven years of age. 
Under this age it is advisable to use a double proportion, or 
even more, of the sulphur ointment. This may be used once 
a day over the entire scalp, the patches themselves being 
rubbed twice a day. In disseminated ringworm of the scalp, 
oleate of mercury (a five per cent, solution in children under 
eight years of age, and a ten per cent, solution in older chil- 
dren) may be used. The oil is to be rubbed in nightly, with 
a sponge mop, care being taken not to allow it to run over 
the face ; a cap should be worn at night. When the scalp 
is very irritable and the application of any of these remedies 
causes inflammation and superficial crusting, the following 
ointment may be used with advantage : — 

R. 01. Cadini ^iss 

Sulphuris ^iss 

Tinct. Iodini ^iss 

Acid. Carbolic tt^xx-xl. 

Adipis Benzoat ^iv. M. 

In weakly children cod-liver oil, arsenic and iron are often 
required, and should always be prescribed if the case seems 
to demand them, or if the eruption spreads from one place 
to another while under treatment. 



TINEA SYCOSIS. 263 

The prognosis of tinea tonsurans should be guarded as to 
the time required to effect a cure. In cases of average severity, 
if there are several coin-sized patches of disease, four months 
of careful treatment will usually be required to effect a cure. 
When the disease is disseminated a much longer time will be 
required. A cure should not be promised, unless all direc- 
tions as to shaving, epilation, etc., are faithfully carried out. 
In cases where kerion forms artificially, or in the course of 
the disease, a more rapid cure may be expected. (See Tinea 
kerion.") 

Tinea Kerion (ix) is an inflammatory and suppurative 
form of tinea tonsurans. It shows smooth, yellowish, reddish 
or purplish patches, more or less raised, cedematous and boggy. 
They are honeycombed and studded with yellowish, suppura- 
tive pits, the openings of the distended hair follicles deprived 
of their hairs, which discharge a mucoid, gummy, honey-like 
fluid. They sometimes itch, burn and pain. In severe cases 
baldness results. The condition sometimes supervenes in a 
mild degree during the treatment of tinea tonsurans. The 
treatment is the same as the latter, excepting that lotions of 
sulphurous acid may be added to the parasiticides above 
mentioned. 

Tinea Sycosis (ix), or ringworm of the beard, is con- 
fined to the hairy part of the face and neck, and is charac- 
terized by inflammation of the hair follicles, with the forma- 
tion of dull-red, fleshy tubercles, with little or no suppuration. 
The disease usually begins with slight redness and scaliness, 
as tinea circinata, but in a few days the hairs begin to be 
affected ; they become dry, brittle and sometimes loose, the 
skin becomes nodular and lumpy, with points of pustulation 
about the hair follicles. The deeper tissues become involved 
later, and thick, raised masses of induration of a dusky, red- 
dish or purplish color appear, giving rise to considerable 
disfigurement; the rapidity of development is sometimes re- 



264 DISEASES OF THE SKIN. 

markable. Though there is usually little or no suppuration, 
yet, now and then, suppuration with crusting maybe profuse, so 
as to mask the essential features of the disease and make it 
look like pustular eczema. The symptoms vary much in 
different cases. Sometimes there is a good deal of burning 
and itching ; at other times there is very little. The affection 
is never so troublesome as simple sycosis. The cause of the 
disease lies in the presence of the ringworm fungus, and the 
structure of the parts alone causes it to differ from the other 
forms of ringworm in appearance. 

The diagnosis of tinea sycosis from simple sycosis is some- 
times difficult ; but there are certain characteristic features 
which must be borne in mind. In T. sycosis there are hard, 
reddish lumps as large as a pea or a cherry, and evidently 
extending down into the skin, while in simple sycosis the 
lesions are superficial pustules on a comparatively smooth, in- 
flamed surface. The hairs in T. sycosis are loose and easily 
pulled out, while in simple sycosis the hairs are firm and the 
attempt to pull them out gives rise to much pain, unless there 
has been a good deal of suppuration about their roots. (See 
Sycosis.') It must be remembered that tinea sycosis is the 
true " barber's itch," and is often contracted in barber shops 
from the use of a razor or shaving brush impregnated with 
fungus from a case of the disease previously shaved. 

The treatment of ringworm of the beard requires both 
epilation and the use of parasticides. Any hairs which are 
loose should be pulled out, all crusts and scales removed, and 
one of the remedies mentioned under tinea tonsurans imme- 
diately applied. In addition to these, lotions of sulphite of 
sodium or of sulphurous acid are often useful. 

Tinea Favosa (ix), or favus, is a vegetable parasitic dis- 
ease, the fungus, however, being of a different species from 
the ringworm fungus. The affection first appears as a dif- 
fused or circumscribed superficial inflammation, with slight 



TINEA FAVOSA. 265 

scaling, followed by the appearance of one or several pin- 
head-sized, pale yellow crusts seated about the hair follicles, 
which develop into the characteristic lesions of the disease, 
raised, sulphur-yellow cups, which can be detached from the 
skin underneath, having a moist, excoriated surface. The 
cups are friable and can be powdered between the fingers. 
They sometimes aggregate into masses. Usually each cup 
has a hair running through its centre. When the disease is 
extensive, ulceration may exist under the crusts. It is 
usually situated in the scalp, but the nails and skin generally 
may be attacked in rare cases. When the nails are attacked 
they become thickened, yellow, opaque and brittle. Favus 
possesses a peculiar odor like musty straw, or like the smell 
of mice. The disease gives rise to some, but not to excessive, 
itching. 

When favus has existed in the scalp to a severe degree and 
for a long time, a cicatricial condition with permanent bald- 
ness may ensue. Favus is a chronic disease. Situated in the 
scalp it requires most energetic treatment to dislodge it, and 
is very prone to relapse. Some pessimistic English observers 
think it can never be totally eradicated, but as met with in 
this country it is curable. It is a rare disease. 

The diagnosis of favus is usually easy ; the peculiar yellow 
cups and the odor are commonly present, and even where the 
shape of the cups has been lost by suppuration or broken 
down by treatment, a patch of characteristic color can usually 
be seen here or there. The mousey odor is almost always 
perceptible, and most cases can be diagnosticated by this 
alone. 

In the treatment of favus of the scalp the hair is to be 
cut as short as possible, after which the crusts are to be 
removed with poultices, or applications of olive or almond 
oil, and soap and hot water, as in pustular eczema of the 
scalp. After they have been removed, the scalp, in severe 
18 



266 DISEASES OF THE SKIN. 

cases, will show pits and depressions, with atrophy, baldness, 
or areas of superficial ulceration, resembling the effects of 
syphilis. Depilation is then to be practiced by means of a 
pair of flat-bladed forceps, especially made for the purpose, 
or by other means. A small patch should be cleared each 
day. Immediately after depilation a parasiticide should be 
applied, and there is none better than a saturated solution of 
sulphurous acid. Sulphur ointment, alone or with tar, may 
also be employed. Yellow sulphate of mercury, half a drachm 
to the ounce, or chrysarobin ointment of the same strength, 
cautiously used, may also be used with benefit. The disease is, 
of course, contagious, and precautions must be taken against 
its transmission, particularly among children in families. 

Tinea Versicolor (ix) is a vegetable parasitic disease, 
which begins by the formation of pin-head and split-pea- 
sized, yellowish spots, usually scattered here and there over 
the affected region. These grow gradually larger and coal- 
esce, forming hand-sized and even extensive patches, with 
extremely irregular margins, sharply defined, against the 
sound skin. There may be only a few patches, or on the 
other hand, the disease may be quite extensive. The patches 
are usually more or less scaly. The disease does not usually 
itch in cool weather, but when the patient grows warm and 
sweats, there is apt to be a good deal of itching. In some 
cases there is never any itching. The chest and back are the 
parts usually and chiefly affected, the disease also spreading 
down the flanks, and over the buttocks, abdomen and groin. 
The disease rarely extends above the shirt collar, below the 
elbows, or below mid thigh. Practically, it is an affection of 
the trunk, which often presents a mapped appearance, owing 
to the peculiar and irregular configuration of the lesions. 
The disease usually spreads slowly, and without treatment 
may continue for an indefinite period. Relapses are not 
uncommon, even when the treatment has been most judicious. 



TINEA VERSICOLOR. 267 

The diagnosis of tinea versicolor is not usually difficult. 
The seat of the disease is usually upon the trunk alone, and, 
wherever else it occurs, it is always to be found there. Vi- 
tiligo, chloasma and the macular syphiloderm are the diseases 
with which T. versicolor is most apt to be confounded. In 
vitiligo, however, the patches are rounded and white ; it is 
the surrounding skin which is dark ; in chloasma the face and 
forehead are the chief seats of the disease, and are rarely 
spared, while in T. versicolor the face is never attacked. 
The macular syphiloderm does not often occur in large 
patches and sheets, and it is not confined to the localities of 
T. versicolor ; also, there are almost invariably concomitant 
symptoms of syphilis. From all these affections T. versicolor 
is distinguished by its proneness to itch. Finally, a microscopic 
examination of a few of the scales, to which a drop of liquor 
potassae has been added, under a power of 350, will show the 
peculiar and characteristic fungus, which, it may be remarked, 
is different from both that of ringworm and that of favus. 

The treatment of tinea versicolor is simple, and, if thor- 
oughly carried out, quite efficacious. The best plan is to 
anoint the affected parts with sapo viridis, well rubbed in 
daily, for a week, avoiding the contact of water. After a 
pause of forty-eight hours a hot bath, with soap, is taken, 
and the disease, if mild and recent, will be found to have 
disappeared. If some remains, the same process may be 
repeated until a cure is effected. A less rapid but more 
agreeable treatment is the daily application of the following — 

R. Hydrarg. Chlor. Corros 7)j 

Saponis Viridis ^ij 

Alcoholis f^iv 

Olei Lavandulae f^j. M. 

This is to be well rubbed in night and morning. Another 
excellent application is sulphite of sodium, in the form of a 
lotion, one drachm to the ounce of water. 



268 DISEASES OF THE SKIN. 

Whatever treatment is employed must be thoroughly ap- 
plied. If a single patch is left untouched the whole disease 
may return. Two or three weeks usually suffices for a cure 
if the remedies have been well applied ; but the patient should 
be inspected a little later, to see if the disease has begun to 
crop out again in some obscure point. 

Tooth Rash. (See Eczema in children.') 

Ulcer. Ulcers may proceed from various diseases, lead- 
ing to necrosis of the skin, or from the effects of traumatism 
or pressure, or varicose veins. Ulcers proceeding from vari- 
ous diseases of the skin, have been touched upon under the 
heads of epithelioma, lupus, syphilis, etc. Varicose and simi- 
lar ulcers require no special description in the present work. 

Ulcer, Rodent. (See Epithelioma.) 

Uridrosis (i) is the name given to an excretion from the 
sweat glands, containing the elements of the urine, especially 
urea. It appears as a colorless or whitish, saline, crystalline 
deposit, or coating, looking as if flour had been sprinkled 
upon the surface. The deposit can be scraped off with a 
knife, and is seen, under the microscope, to present minute 
crystalline spiculae. The disease is very rare. In most of 
the cases reported, partial or complete suppression of the 
renal function with disease of the kidneys and uraemic poison- 
ing were present. 

Urticaria (ii) is an inflammatory disease of the skin, 
characterized by the development of wheals of a whitish or 
reddish color, accompanied by sticking, pricking, tingling 
sensations. The lesions are apt to come out suddenly and 
disappear again in a very short time, so that patients seeking 
advice are often unable to show a sign of the disease, except- 
ing scratch marks, even at repeated visits to the physician, 
when they may have been tortured and disfigured by it be- 
tween times. The wheals are of various sizes, sometimes as 
small as a split pea, sometimes as large as the palm of the 



URTICARIA. 269 

hand. They average finger-nail size. While the smaller 
lesions are usually round, the larger ones may be very irregu- 
lar, crescentic or linear ; often they assume a grotesque out- 
line. They may be barely elevated above the skin, or may 
rise to an eighth of an inch in height. They may be soft 
or firm to the touch, and whitish or pinkish in color. On 
the face the urticaria rash may cause great temporary de- 
formity. The lip, or half the lip, for instance, may within 
a few minutes swell out to a great size, and remain thus for 
an hour or more. The eruption burns, stings and tingles, as 
if the skin had been stung by nettles, hence the popular 
English name of the disease, " nettle rash," while in this 
country it is generally called "hives." Sometimes these 
sensations of burning and tingling are merely annoying ; at 
other times they may prove distressing to the last degree. 
Rubbing and scratching commonly aggravate the disease, 
bringing out new wheals. 

The lesions of urticaria frequently change their locality, 
the eruption appearing now in one part of the body, and 
again in another. It occurs at all ages and in both 
sexes. Its duration depends entirely upon the presence or 
removal of the exciting cause There are several varieties 
of urticaria: — i. Urticaria papulosa, which occurs com- 
monly among children, in the form of widely dispersed, 
pin-head to split-pea-sized, flat or acuminated papules, which 
appear suddenly, and last for hours or days. It is attended 
by severe itching. 2. . Urtica?'ia hemorrhagica, which is, in 
fact, urticaria occurring in the seat of a purpuric eruption. 3. 
Urticaria bullosa, where the wheals are transformed into blebs, 
which may assume some of the characteristics of pemphigus. 
4. Urticaria tuberosa, occurring in the form of large walnut or 
even egg-sized, firm, more or less persistent nodes or tumors, 
resembling somewhat exaggerated tumors of erythema no- 
dosum. 



270 DISEASES OF THE SKIN. 

Urticaria may be acute or chronic. The acute variety is 
usually, though not invariably, ushered in by slight febrile 
symptoms, languor, headache, depression, gastric disturbance, 
furred tongue, etc. The rash appears suddenly, and may 
involve the whole body, or a portion only, accompanied by 
intense, and almost intolerable, burning and stinging sensa- 
tions. In a variable time, from one hour to a day, the 
symptoms subside and the eruption disappears, without 
leaving a trace, except in the form of scratch marks. Chronic 
urticaria may continue for months and years, or indeed, as 
long as the cause exists. The individual lesions, which are 
usually small, come and go as in the acute form ; crop after 
crop may appear, the skin being hardly ever free from them. 
The patient's general health may appear fair. 

The causes of urticaria are numerous and of a very diverse 
character. Certain external irritants and poisons to the skin, 
as the stinging-nettle, jelly-fish, caterpillars, fleas, bed-bugs 
and mosquitoes, are not unfrequent causes. Among internal 
causes, gastric and intestinal derangements are by far the 
most common. An overloaded stomach, excess in wine, 
beer, or highly seasoned food, may occasion an attack, while 
certain articles of food, as fish, oysters, clams, crabs, lob- 
sters, pork, especially sausage, oatmeal, mushrooms, rasp- 
berries and strawberries, are all apt to bring out the eruption. 
Various drugs have the same effect (see Dermatitis medica- 
mentosa) in some individuals. In most cases of urticaria 
from these causes a certain idiosyncracy seems to exist. Any 
irritation of the bowel, as by worms, in children, may bring 
out the eruption. Sudden emotion or mental excitement in 
certain persons may also produce it. In females menstrual 
and uterine difficulties may cause urticaria. The disease is 
intimately connected with the nervous system, and patients 
who suffer from chronic urticaria are apt to be persons of 
more or less depraved nervous organization. 



URTICARIA. 271 

The diagnosis of urticaria does not often present any diffi- 
culty, because the lesions are so peculiar in appearance, and 
because of the peculiar burning and tingling sensations. The 
small lesions, as found in children, may be mistaken for 
eczema, but a few scratches with the finger nail on the skin 
of any part of the body will arouse urticarial red or white 
bands and streaks, which show an irritable condition of the 
skin and are very characteristic. 

The treatment of urticaria depends greatly, for its success, 
upon the discovery and removal of the cause. When this is 
suspected to be some gastric disturbance, the precise articles 
of food of which the patient has been partaking should be 
inquired into ; their quality, as to freshness, etc., should also 
be a matter of scrutiny. The possibility of the patient having 
eaten anything unusual should also be considered, as well as 
the previous ingestion of medicine. An emetic may be given 
in acute cases, if the contents of the stomach have been 
recently ingested, and are suspected of being the cause. The 
bowels also should be freely opened by a saline purgative. 
The diet should be of the most simple and unstimulating 
character, and the subsequent internal treatment should be 
directed against the digestive difficulty. The treatment in 
any given case must depend upon the result of a careful 
investigation into its nature and cause. 

Among medicines the laxative mineral waters are often 
advantageous ; Hunyadi Janos,OfenerRacoczy, Friedrichshall 
or Hathorn ; the latter preferably drunk at the spring in 
Saratoga. The alkaline waters, as Vichy or Saratoga Vichy, 
may also at times be used with advantage. Diuretics are 
often of use. Quinia is a most useful remedy, whether 
malaria be present or not. Arsenic is sometimes of service 
when other remedies fail. Iron also is useful. The "Mistura 
ferri acida," already several times referred to, is a very useful 



272 DISEASES OF THE SKIN. 

remedy in many cases of urticaria. The formula may be 
given again here : — 

R. Magnesii Sulphat %) 

Ferri Sulphat gr. iv 

Sodii Chloridi ^ss 

Acidi Sulphurici, dil... 1*3 ij 

Infus. Quassiae ad f Jji v « M. 

SiG. — Tablespoonful in a tumbler of water, before breakfast. 

Bromide of potassium, chloral and other sedatives may be 
required, to give rest and calm to the nervous system, often 
injured by long-continued suffering. The preparations of 
opium should generally be avoided. Among other remedies, 
to be tried in difficult cases, may be mentioned the following : 
Sulphate of atropia, in doses of T fo to -&o grain, morning and 
evening; sulphurous acid, in drachm doses, diluted with 
simple syrup ; salicylic acid, in 20-grain doses, thrice daily, 
and chloride of ammonium, in 10- to 20-grain doses, thrice 
daily. All of these I have been obliged to use at one time 
or another, and I have used each with satisfaction. 

External treatment is of importance to calm the burning 
and tingling pain of the eruption, which is at times almost 
unendurable. Alkaline baths, followed by soothing powders, 
such as are described under the treatment of acute eczema, 
will be of use. Sponging with vinegar and water, or alcohol, 
alone or diluted, often gives relief; it should be used fre- 
quently. Carbolic acid, three drachms, with an ounce of 
glycerine in a pint of water, is an excellent wash. Chloro- 
form, a drachm to the ounce of alcohol, or a drachm to the 
ounce of cold cream, is very good. Dilute ammonia water 
is useful in some cases. Occasionally a saturated solution of 
benzoic acid in water (3ss ad Oj) is effectual. When one 
local remedy fails, another should be tried. Irritating under- 
clothing should be avoided, and the patient should sleep in 
a cool room, with light bed covering. 



VACCINATION, SKIN DISEASES FOLLOWING. 273 



The prognosis in urticaria varies in each case. If the cause 
is a temporary gastric derangement, its removal will soon 
result in a cure. If, however, the urticaria is chronic and 
dependent upon some derangement of the nervous, digestive 
or generative system of long standing, it is apt to prove very 
stubborn. 

Vaccination, Skin Diseases Following. In addition 
to the inoculation of syphilis by vaccination, an event of 
such rare occurrence as not to require description in the 
present work, there are several skin affections which appear 
to arise as a result of a general irritation in predisposed con- 
stitutions, which are worthy of note. These assume the fol- 
lowing forms : i. Erythema vaccinia (already described under 
Erythema). 2. A herpetiform eruption, which shows itself in 
the form of a number of closely-grouped vesicles, appearing 
on the third day after vaccination, at the seat of the opera- 
tion, surrounded by a red areola and itching severely. Some- 
times eczema, with swelling of the axillary glands, results. 
It is apt to occur in weakly or anaemic children. 3. A pem- 
phigoid eruption, when a bulla forms, instead of the usual 
vesicle, at the seat of inoculation. This may be followed by 
ulceration and cicatrization. It occasionally occurs as an 
epidemic. 4. A furunculoid eruption, in which red tuber- 
cles as large as peas appear at the seat of vaccination These 
tubercles afterward suppurate. They correspond to ordinary 
follicular furuncles. 5. Vaccinal erysipelas sometimes makes 
its appearance, usually on the seventh to the tenth day after 
vaccination. It consists in the formation of a broad, red 
ring, which rapidly increases in extent. It is attended with 
swelling, tension and pain, and presents the usual characters 
of erysipelas. It sometimes spreads down the forearm, or 
even as far as the fingers, or up the arm to the axilla and 
chest. It is, of course, accompanied by general febrile and 
other symptoms. 6. Vaccinal ulcers sometimes occur, in 



274 DISEASES OF THE SKIN. 

place of the ordinary evolution of the vaccine vesicle. These 
are due to the setting up of a very intense morbid process in 
the skin of the part, rather than to any particular idiosyn- 
crasy of the person vaccinated, or to any specific change in 
the blood. 7. Gangrene has been known to occur in weakly 
children, the crusts being converted, on the twenty-fifth day 
after vaccination, into a black, fetid, gangrenous eschar. In 
one case reported, death ensued. 

Vegetations. (See Verruca and Syphilis, skin diseases 
dice to.) 

Venereal Wart. (See Verruca.') 

Vernix Caseosa. (See Seborrhoea.) 

Verruca (iv), or wart, presents itself in several different 
forms. In addition to the common wart, as met with on the 
hands and elsewhere, there is a flat variety, usually about 
the size of the finger nail, and only slightly elevated above 
the level of the skin. This is apt to be met with on the face 
and on the backs of the hands, and, from being found most 
frequently in elderly people, is called verruca senilis. Besides 
these forms of wart, there is the verruca acuminata, or pointed 
wart, consisting of one or more groups of acuminated or 
irregularly-shaped elevations, composed of greatly elongated 
papillae of the skin, usually packed together so as to form a 
more or less solid mass of "vegetations." The individual 
prominences maybe pointed, clubbed, or more or less sessile 
or pedunculated. In color, they are pinkish or reddish, 
bright red or purplish, depending on their situation and 
vascularity. They are apt to occur about the genitalia (penis 
and labia) of both sexes. Upon the penis, they generally 
spring from the glans and inner surface of the prepuce. 
Upon the female, they generally spring from the inner surface 
of the labia and vagina. They are also found about the anus, 
mouth, axillae, umbilicus and toes. About the genitalia their 
surface is usually moist, and they exhale a disgusting odor, 



VERRUCA. 275 

due to the decomposition of the secretions on their surface. 
They grow rapidly, and may attain large size and assume 
grotesque and misshapen forms. 

The causes of warts are obscure. The acuminated variety, 
as it occurs on the genitals, is often, but by no means always, 
venereal in origin, and may be due to the irritation of acrid 
discharges, as gonorrhoea. They are never a manifestatiofi 
of syphilis, and the vegetating syphiloderm must not be con- 
founded with the growth under consideration. The wart is 
simply an hypertrophy of the papillae, the connective tissue 
element being more prominent in the pointed variety, or con- 
dyloma. 

Small warts may be clipped off with curved scissors, the 
base being touched with nitrate of silver stick. The dermal 
curette or scraping spoon may also be employed. The liga- 
ture, ecraseur or galvano-caustic wire may be employed in 
the larger, vascular variety. Venereal warts about the labia 
are best treated by washing the parts with dilute liquor sodae 
chlorinatse, and afterwards dusting the surface with powdered 
calomel, or a powder composed of equal parts of burnt alum 
and savin. Glacial acetic, nitric, chromic or carbolic acids 
may be used. The larger condylomata may be attacked by a 
Paquelin's cautery. Common warts may be cauterized by 
one of the acids mentioned, or by means of caustic potash, 
in stick or solution. Tincture of the chloride of iron is 
sometimes used successfully. The following prescription is 
in vogue at the present time. It answers excellently in many 
cases: — 

R. Ext. Cannabis Indicse gr. x 

Acid Salicylici ^ss 

Collodii ^j. M. 

Apply daily, for three or four days, and then scrape the wart, and if 
necessary apply again. 

For patches of warts the following paste may be used, only 



276 DISEASES OF THE SKIN. 

not covering too much ground at a time, for fear of absorp- 
tion: — 

R. Pulv. Acidi Arseniosi gr. vj 

Ung. Hydrarg. 

Empl. Hydrarg..aa, q.s.,ad.. £ij. M. 

The mixture should be made into a soft plaster, and applied 
on thin kid. The warts melt down gradually under its use. 

Now and then warts resist all treatment, or spring up as 
fast as removed. In such cases arsenic may be given with 
some hope of preventing the recurrence of the growths. It 
should be administered for months, as its action is only slowly 
felt in the economy. Occasionally the presence of warts 
seems due to some nervous or constitutional influence, and 
they stubbornly resist all treatment. 

Verruca Necrogenica. (See Dissection wound.) 

Vitiligo (v) shows itself in the form of one or more, 
usually sharply defined, rounded, ovalish or irregularly-shaped, 
variously-sized and distributed, smooth, whitish spots, around 
the borders of which the surrounding skin shows an increase 
of pigment. The number of spots is usually not numerous ; 
they are smooth and on a level with the surrounding skin, 
and save for the discoloration cannot be distinguished from 
it. The texture of the affected skin is indeed normal, except 
that the amount of pigment has diminished, a diminution 
which extends to the hairs growing on it, which usually turn 
white. The disease is popularly known as "piebald skin," 
and when occurring in the negro, has sometimes given rise 
to the notion that the skin was turning white, like that of a 
Caucasian. The disease is striking and disfiguring. It some- 
times disappears spontaneously after years, but treatment has 
little effect. Arsenic is the only remedy which, in my 
experience, has had a good effect, when used for months. 
Treatment, however, on the whole, is unsatisfactory. The 
disease is sometimes mistaken for Morphcea, Macular leprosy 



ZOSTER-ZONA. 277 

and Chloasma. A reference to the description of these dis- 
eases will show wherein they differ. 

Wart. (See Verruca?) 

Wen. (See Sebaceous cyst.) 

Xanthelasma. (See Xanthoma.') 

Xanthoma (vi) is characterized by the formation of yel- 
lowish, pea-sized or larger, patches of various sizes, either 
flat with the skin or in tubercles and raised masses. The flat 
variety generally occurs on the eyelids, when the patches look 
like bits of chamois skin inserted in the lid. The tubercular 
form occurs usually elsewhere than on the eyelids. The lesions 
of both varieties are usually single or few in number, but are 
now and then numerous. They rarely give rise to any sensa- 
tion but occasionally pain slightly. They used to be thought 
connected in some way with disease of the liver, but such 
connection has never been proved. The treatment is ex- 
cision. 

Xeroderma. (See Ichthyosis and Atrophy of the skin.) 

Yaws. (See Frambcesia.) 

Zoster — Zona.. (See Herpes zoster.) 



APPENDIX. 



DIET IN DISEASES OF THE SKIN. 

While there are many diseases of the skin which are purely 
local processes, or which are dependent upon general causes 
beyond the present ability of medical art to obviate, there are 
others, and among these some of the most important, as 
eczema, urticaria, acne, etc., in the management of which 
hygiene and dietetics play a most important part. Some 
allusion has been made to this point in treating of the various 
diseases in the foregoing pages, but it has seemed desirable 
to draw further attention to the subject in this place, and to 
give some general suggestions and hints which may be devel- 
oped to suit the individual case. 

And first, with reference to the part of the physician in 
giving counsel on this matter. The time spent in interro- 
gating the patient with reference to his hours of meals, 
habits of eating, favorite foods and drinks, the effects of 
different articles of diet upon his digestion, so far as he may 
have observed himself in this matter, etc., is by no means 
lost. Having formed an opinion as to the condition of the 
digestive organs, so far as stomachal digestion is concerned, 
the inquiry should be pushed further, and the intestinal 
digestion and habits of defecation should be examined into. 
In many cases the simple knowledge of the existence of con- 
stipation or diarrhoea, or of the regular performance of de- 
fecation, is all that is necessary, but in some instances it may 
be desirable to push the inquiry further. 

Having come to a conclusion as to the points at fault, full 

279 



280 APPENDIX. 

and explicit directions as to diet and regimen are to be given 
the patient, as a great deal depends upon the care and tho- 
roughness with which the physician's advice is followed. 
The exact diet suitable to the individual must be decided 
upon and enforced in such terms as to leave no doubt in the 
patient's mind as to the importance of every detail. Gener- 
alities in the way of directions, with a careless indication, in 
broad terms, of the articles of diet to be used and avoided, 
are not likely to produce a serious impression on the patient's 
mind, and the failure to amend is followed by a general 
despondency and distrust of all remedies. 

It is obviously impossible, even if this were the place, to 
give a complete disquisition on diet in dyspepsia and weak 
digestion. Each case must be treated on its own merits. 
Inquiry should be made as to the particular articles of food 
which agree, so as to ascertain the form of dyspepsia which is 
present. I think it advisable, in many cases, to give the 
patient a list of such articles of diet as are commonly found 
upon our tables, marking such as are deemed suitable or un- 
suitable, and making such changes subsequently as the expe- 
rience of the patient indicates. This list is arranged as 
follows : — 

DIGESTIBLE FOODS. 

Meats. Sweet bread, plainly cooked. Chicken and turkey 
(white meat). Venison. Partridge. Pheasant. Pigeon 
(squab). Wild duck. Rabbit. Lamb, roast, stewed or in 
broiled chops. Mutton, roast or in broiled chops. Beef, 
roast or in rare tenderloin steak. Eggs, soft boiled. Tripe. 
Oysters, raw, roast, broiled or stewed (always rejecting the 
"eyes"). Fresh fish, especially trout, perch and flounders. 
Meat broths and clear soups, carefully made, not rich, and 
without vegetables. 

Vegetables. Rice. Maccaroni. Spinach. Tomatoes 
(stewed). Peas (fresh and young). Beans (Lima, French 



APPENDIX. 281 

and string, young and fresh). Squash. Carrots (young). 
Asparagus. Oyster Plant or Salsify (stewed). Mushrooms. 
Beets. Okras. 

Bread, etc. Dry and milk toast. Zwiebach. Toasted 
rusk. Steamed crackers. Wheat bread, rather stale, and 
preferably the crust). Rolls. Graham bread. 

Beverages. Coca, made from the nibs. Weak Tea, with a 
slice of lemon instead of sugar and cream. Coffee, with a 
raw, beaten egg instead of milk, sweetened with sugar or 
extract of malt. Milk in small quantities at a time. Apolli- 
naris water. 

QUESTIONABLE FOODS, 

Such as are borne by some weak digestions, while disagreeing 
with others or at certain times. 

Meats. Reed birds. Duck. Black meat of chicken or 
turkey. Omelette. Scrambled eggs. 

Vegetables. Potatoes, white. Parsnips. Stewed Celery. 
Raw Celery. Hominy. Egg Plant. Water-cress. Onions. 
Foreign fruits, as Bananas, Oranges and Grapes. (The usual 
summer fruits, when perfectly fresh and in season, agree with 
almost every one.) 

Bread, etc. Fresh wheat bread. Graham bread and bis- 
cuit, when hot and fresh. Oatmeal mush. Indian mush. 
Cracked wheat. 

Puddings (boiled and baked), as custard, bread, farina, 
corn starch, tapioca, etc. Stewed fruits. Curds and cream. 
Plain cakes, as rusk, bun, etc. Ice cream. 

B.uids. Coffee and Tea, strong, with sugar and cream. 
Chocolate, as usually prepared. Lemonade. Ginger ale, 
and the like. 

INDIGESTIBLE FOODS, 

Such as are commonly found to disagree with persons of 
weak digestion, or suffering from the various forms of dys- 
pepsia. 

19 



282 APPENDIX. 

Meats. Ham. Pork in any shape. Sausage. Corned 
beef. Dried beef. Veal. Goose. Kidneys. Liver. 

Salt fish or smoked fish, as Cod. Mackerel. Salmon or 
herring. 

Shell fish, as Lobsters. Crabs. Clams, and the "eyes" 
of oysters. 

Hard boiled eggs. 

Vegetables. Cabbage. Sauer-kraut. Cauliflower. Lettuce 
and salads of all sorts. Cucumbers. Pickles. Corn. Raw- 
celery. White potatoes, (new). Sweet potatoes. Dried 
fruits, as Raisins. Figs, etc. Nuts. Water ices. Preserves. 

Bread, etc. Hot bread, and especially hot griddle, and 
other breakfast cakes. Fritters. Dumplings. Puddings of 
boiled flour. Pastry of all sorts, and rich cakes. Cheese. 

Fluids. Alcoholic and malt liquors of all kinds generally 
disagree with dyspeptics, and should not be taken except as 
prescribed. Syrups and gaseous beverages are also unwhole- 
some. 

In a general way salted and fried foods are to be avoided. 
Also too much fat ; but butter, which is one of the most 
digestible fats, and which to most people adds a zest to 
restricted diet, should in almost all cases be permitted. 
Pickles, preserves, and candied or dried fruits, should be 
prohibited. Patients should be instructed (for this advice is 
often required), to eat slowly, chew carefully, and not to 
deluge the stomach with water or other fluids during meal 
time, especially at the beginning. 

In cases of actual dyspepsia, considerable comfort is often 
gained by dividing the animal from the vegetable food, 
taking one at one meal, and the other at another. Vege- 
table food is much less likely to cause flatulence if taken 
alone. 



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